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RC311  .Ot4  Tuberculosis :  its  c 


RECAP 


TUBERCULOSIS 

M  niS  CAUSE  CURE  AND  PREVENTION 


\t^>.\ 


DWARD  O.  OTIS,  M.D. 


■^c^w 


Cb^^- 


([l0lumbta  UttttiFratlg 
in  tl]0  (Sitg  0f  N?uj  fork 


IS^etnmsi  ICibrarg 


(A-'^t. 


Discoverer  of  the  Tubercle   Bacillus. 


TUBERCULOSIS: 

ITS    CAUSE,   CURE 
AND  PREVENTION 


A  REVISED  EDITION  OF 

"THE  GREAT  WHITE  PLAGUE" 
(A  BOOK  FOR  LAYMEN) 

BY 
EDWARD  O.  OTIS,  M.D. 

Professor  of  Pulmonary  Diseases  and  Climatology,  Tufts  College 
Medical  School ;  late  President  of  the  Boston  Tuberculosis 
Association;  late  Visiting  and  Consulting  Physician  to 
the  Massachusetts  State  Sanatorium  ;  member  of  the 
National  Tuberculosis  Association;  Correspond- 
ing   Member  of   the  International  Anti- 
Tabercalosis    Association,    etc.,    etc. 


NEW  YORK 

THOMAS  Y.  CROWELL  COMPANY 

PUBLISHERS 


Prof.  J.  McK.  Cattell 

Copyright,    1909, 
By    THOMAS    Y.    CROWELL   &    CO. 

Copyright,    1914, 
By   THOMAS   Y.    CROWELL   COMPANY, 


Published  March,   19 14. 


'U 


TO  GEORGE  ADAMS  LELAND,  M.  D. 

A  friend  of  years,  through  whose  kindly  in^ 
terest  this  book  was  written. 


"  The  Modern  Crusade  against  tuberculosis 
brings  hope  and  bright  prospects  of  recovery 
to  hundreds  and  thousands  of  tAc tints  of  the 
disease  who  under  old  teachings  were  aban- 
doned to  despair," 

Theodore  Roosevelt. 


PREFACE 

In  the  following  pages  an  attempt  has  been 
made  to  present  the  simple  facts  of  tuberculo- 
sis in  such  a  form  as  will  be  intelligible  and 
interesting  to  the  layman.  A  decade  or  more 
ago,  no  one  would  have  entertained  the  idea 
of  publishing  a  popular  book  upon  this  sub- 
ject; but  since  that  time  the  great  Crusade 
against  tuberculosis  has  become  so  universal 
and  prominent,  that  to-day  the  subject  excites 
the  deepest  interest  in  almost  every  commu- 
nity, and  the  people  are  everywhere  eager  to 
learn  the  essential  facts  with  regard  to  its 
cause  and  cure. 

Many  things  have  been  repeated  advisedly, 
as  the  subject  has  been  viewed  from  differ- 
ent standpoints.  Naturally  there  still  remain 
unsettled  problems  upon  tuberculosis;  but 
the  narrative  has  been  presented  in  the  light 
of  the  present  knowledge  of  the  subject,  and 
with  an  absolute  adherence  to  definitely  es- 
tablished facts.  Thanks  to  the  unceasing  ef- 
forts of  investigators  in  many  lands,  we  now 
possess  sufficient  knowledge  of  so  final  and 

y 


PREFACE 

definite  a  character  as  to  render  it  possible  to 
wage  this  momentous  campaign  with  an  as- 
sured hope  of  success  in  the  prevention  and 
ultimate  eradication  of  the  "  Great  White 
Plague."  Wonderful  strides  have  been  made, 
in  the  last  few  years,  in  both  discovering  the 
secrets  of  this  world-wide  disease,  and  also  in 
educating  the  general  public  upon  the  subject. 
The  future  prospect  is  most  hopeful;  and  the 
rapidity  with  which  the  end  can  be  achieved 
will  depend  upon  the  efforts  of  every  indi- 
vidual, and  the  material  aid  which  both  people 
and  governments  will  contribute  towards  it. 

E.  O.  O. 
Boston,  July  i,  1909. 


PREFACE  TO  REVISED  EDITION 

Since  this  book  was  published  under  the 
title  of  "  The  Great  White  Plague,"  four  and  a 
half  years  ago,  no  startling  discovery  has  been 
made  either  regarding  the  nature  or  the  cure 
of  tuberculosis;  nor  have  the  methods  of 
fighting  the  disease  been  materially  changed. 
The  open-air  treatment  still  maintains  its  su- 
premacy, and  experience  has  demonstrated  the 
value  of  the  preventive  measures  then  in  use. 
Only,  the  fight  has  become  more  universal, 
more  determined,  and  more  intense,  with 
larger  forces  and  material  resources.  In  this 
revision  the  form  and  substance  of  the  book 
have  been  retained  and  only  such  changes  and 
additions  have  been  made  as  new  data  and  in- 
creased experience  and  knowledge  have  ren- 
dered necessary  to  bring  it  up  to  date. 

Tuberculosis  still  prevails  to  an  enormous 
extent,  but  it  is  steadily  decreasing,  with  no 
reason  to  suppose  that  it  will  not  continue  to 
do  so,  though  with  perhaps  lessened  rapidity. 
The  past  success  brings  courage  and  hope,  and 
"  so  long  as  we  are  fighting  with  hope,"  says 
Sir  William  Osier,  "  the  victory  is  in  sight." 

E.  O.  O. 

Boston,  January  i,  1914. 

vii 


CONTENTS 

CHAP.  PAGE. 

I.  Tuberculosis,    Its   Prevalence  and 

Its  Significance     ....;.       i 

Great  epidemics  of  the  Middle  Ages — 
Universality  of  Tuberculosis^ — Tuber- 
culosis compared  with  great  disasters 
and  wars — The  old  feeling  of  hopeless- 
ness— The  saddest  fact  of  all — Tuber- 
culosis and  pneumonia  compared — 
Economic  loss  from  tuberculosis — Ef- 
fect upon  different  races — Sex  and 
tuberculosis. 

II.  What  Is  Tuberculosis?     Its  Na- 

ture AND  Cause  .  ...  23 
Description  and  location — Dr.  Koch's 
discovery — ^Value  of  animal  experimen- 
tation— Nature  of  the  tubercle  bacillus 
— Dry  sputum  alone  dangerous — How 
to  control  the  disease — A  "house  dis- 
ease"— How  bacilli  enter  the  body — 
Infected  milk. 

ix 


CONTENTS 

CHAP.  PAGE. 

III.  Tuberculosis  a  Contagious  or  In- 

fectious Disease:    What   This 
Means 38 

What  is  a  contagious  or  infectious  dis- 
ease ? — Acute  infectious  diseases — 
Chronic  contagious  diseases — "  Con- 
sumption terror  " — The  only  way  con- 
sumption  is   conveyed. 

IV.  Inheritance    and    Immunity      .     47 

The  old  idea  versus  the  new — What 
is  "  inheritance  ?  " — Predisposition  and 
immunity — Antitoxins  and  vaccines — 
Immunity   in    acute   diseases. 

V.  The  Seed  and  Soil 58 

Two  things  necessary  to  contagion — 
The  favorable  soil — The  "  neglected 
cold " — Overcrowding  as  a  cause  of 
tuberculosis — Fresh  air  and  sunshine — 
Evils  of  inadequate  respiration — Value 
of  proper  food — Defective  teeth — Al- 
cohol makes  the  bed  of  tuberculosis — 
Injurious  occupations  —  Over-fatigue 
and  over-exertion — Worry — Monotony 
of  occupation. 

VI.  The  Recognition  and   Symptoms 

of  Tuberculosis 82 

Early    symptoms — How    the    lungs    are 


'      CONTENTS 

CHAP.  PAGE. 

tested — Examination    of    the  sputum— 
The     tuberculin     test— The     X-Ray — 

"  Closed  "   tuberculosis— The  only   safe 
way — Points  to  remember. 


VII.  The  Curability  of  Tuberculosis 

AND  Its  Treatment  ....  98 
Formerly  regarded  as  hopeless — Useless 
remedies — ^The  true  theory  of  treat- 
ment— The  out-door  treatment — From 
in-door  to  out-door  life — Rest  in  the 
cure — The  sanatorium  and  its  advan- 
tages— Alleged  objections  to  the  sana- 
torium— No  medicine  used  in  the 
sanatorium — Seventy  per  cent,  cured  or 
arrested  in  the  early  stage. 


VIII.  The  Home  Treatment  of  Tu- 
berculosis       118 

The  room  of  the  consumptive — Care  of 
the  sputum — How  the  day  should  be 
spent — Day  camps  and  classes — Sleep- 
ing arrangements  —  Exercise  —  Food — 
The  hardening  process  and  the  cold 
bath — Clothing — Precautions  and  mode 
of  life  after  recovery — A  suggestive 
daily  routine — Some  aphorisms  of  the 
tuberculosis  patient. 
xi 


CONTENTS 

CHAP.  FACE. 

IX.  Tuberculosis  and  Climate     .     .  142 

Unhygienic  conditions  in  cities — Con- 
sumption rare  in  out-door  life — Climate 
only  one  factor — The  most  favorable 
climate — ^Why  a  change  of  climate — 
Selection  of  a  climate — The  essential 
climatic  factors — Various  health  resorts 
in  America — Health  resorts  in  Europe 
— Dr.  Knopf's  ideal  climate. 

X.  The  Prevention  of  Tuberculosis  163 

The  direct  attack — The  educational  cam- 
paign— ^The  tuberculosis  exhibition — 
The  traveling  exhibition — The  service 
of  the  public  press — Cumpulsory  noti- 
fication— ^The  tuberculosis  dispensary 
— The  isolation  of  the  dangerous  con- 
sumptive— Compulsory  notification  and 
disinfection  no  new  thing — Methods  of 
disinfection — The  indirect  means  of 
prevention — Tuberculosis  a  social  dis- 
ease— Better  tenement  houses — Prohi- 
bition of  liquor — Pure  air — Important 
points  to  remember — A  clean  house 
and   dust— Spitting   and   cuspidors. 

XI.  The  Great  Crusade  against  Tu- 

berculosis     193 

Organized  efforts   almost  universal — In- 
ternational      congresses — The       move- 
xii 


X 


CONTENTS 

CHAP.  PAGE. 

ment  simultaneous  among  all  peoples 
— Why  a  crusade  against  a  single  dis- 
ease— Principal  forms  of  activity — 
Germany— Compulsory  insurance  of 
workingmen  —  Information  bureaus — 
Other  forms  of  tuberculosis  work  in 
Germany  —  England — Ireland— France 
— Sweden  —  Denmark — Switzerland — 
Belgium — Norway — Tuberculosis  work 
in  other  countries — Canada  and  Breh- 
mer  Rest — The  tuberculosis  crusade  in 
the  United  States — The  price  of  a  bat- 
tleship for  the  tuberculosis  crusade — 
What  the  United  States  Government  is 
doing — The  National  Tuberculosis  As- 
sociation— The  Red  Cross  stamps — 
The  clergy  and  churches  and  societies 
— Governors  and  legislatures — New 
York  —  Pennsylvania — Massachusetts — 
Scientific  activity  in  the  study  of  tuber- 
culosis— Effect  of  the  tuberculosis  cru- 
sade. 


XII.  Tuberculosis  and  the  Child     .  227 

How  children  contract  tuberculosis — 
Milk  infection — House  infection — 'Tu- 
berculosis not  decreasing  in  children — 
Children  in  infected  homes — A  tuber- 
culous mother  should  not  nurse  her 
infant — Feeding  school  children — How 
to  treat  children  with  tuberculosis — A 
xiii 


CONTENTS 

CHAP.  PAGE. 

typical  out-door  school  —  Hygienic 
school  buildings — Rules  for  children — 
Teachers  and  tuberculosis — The  home 
and  tuberculosis — A  complete  pro- 
gramme. 

XIII.  The  Government  and  Tuber- 
culosis       252 

The  government  should  protect  the 
health  of  the  people — What  former 
President  Roosevelt  says — State  gov- 
ernments and  tuberculosis — A  compre- 
hensive scheme  for  the  state — City 
governments  —  Large  appropriations 
necessary^ — What  foreign  nations  are 
doing. 

XIV.  The  Factory  and  the  Work- 
shop IN  Their  Relation  to  Tu- 
berculosis      266 

Importance  of  protecting  the  health  of 
wage-earners — Remedies  for  evils  of 
industrial  infection — What  is  now  be- 
ing done — The  plan  of  mutual  aid  in 
Connecticut — Better  conditions  of  fac- 
tory life— Mortality  from  dusty  trades 
— The  peril  of  the  sweat  shops — The 
remedy  for  dust  in  factories — Depart- 
ment stores  and  shops — Waiters,  nurse 
girls,  and  servants — Tuberculosis  in 
prisons — ^Tuberculosis  in  insane  asy- 
lums. 

xiv 


CONTENTS 

CHAP.  PAGE. 

XV.  The    Future    Outlook     .      .     .  288 

Resolutions  of  the  International  Con- 
gress— A  look  forward — some  statis- 
tics of  the  diminution  of  tuberculosis 
— The  advance  in  the  future — The  open- 
air  school  in  the  future — Another  influ- 
ence,  peace   between  nations. 

XVI.  The  Lungs  and  Their  Use     .  305 

Why  do  we  breathe? — The  cavity  which 
contains  the  lungs — ^The  mechanism  of 
respiration  —  The  upper  respiratory 
tract — Size,  weight  and  capacity  of  the 
lungs — Inadequate  respiration  a  danger 
— We  should  breathe  through  the  nose 
— Importance  of  pure,  fresh  air — Res- 
piratory exercises — The  corset — The 
habit   of  full,   free   respiration. 

Fresh  Air   .     .     .     .     ....     .  322 

Health  Rules 323 


XV 


v^ 


ILLUSTRATIONS 

Robert  Koch,  Discoverer  of  the  Tubercle 

Bacillus Frontispiece 

OPPOSITE    PAGE 

Theophile  Laennec,  Discoverer  of  Aus- 
cultation        86 

Sleeping  with  Heads  out  of  the  Windows  lOO 

Sleeping  Porches io6 

A  Winter's  Day  at  the  Sanatorium — A 

Sun  Bath no 

The  "  Shack  "  for  the  Open-Air  Treat- 
ment        ii6 

The  Walsh  Window  Tent 120 

Keeping  Warm  in  Winter  while  Taking 

the    Cure 124 

Sleeping  Out-of-Doors,  "  the  Sky  for  a 
Roof" 132 

Davos  in  Switzerland,  the  Great  Resort 

for  the  Tuberculous   .....   160 

A  Tuberculosis  Dispensary     ....   172 

The  Vanderbilt  East  River  Homes   .      .  208 

An  Open-Air  School  Room  in  Boston  .  242 

An  Open-Air  School  in  Philadelphia     .  246 

Rest  Hour  in  an  Open-Air  School  .      .  250 

A  Typical  Open-Air  School  ....  300 


I.  TUBERCULOSIS— ITS  PREVALENCE 
AND  ITS  SIGNIFICANCE 

^^^^^  UBERCULOSIS  or  consumption 
M  ^^\  has  been  aptly  called  the  "  Great 
B  J    White  Plague."     We  might  also 

^^^^  call  it  the  "  Silent  White  Plague," 
for  although  it  is  a  veritable 
plague  in  its  universal  and  great  prevalence, 
as  we  shall  see  directly,  yet  it  so  slowly  .and 
silently  seizes  upon  its  victims,  and  the  world 
has  grown  so  accustomed  to  it,  that  it  pos- 
sesses little  of  that  dramatic  incident  attend- 
ant upon  its  ravages  that  the  plague  of  old 
had  in  its  sudden  and  appalling  visitation 
upon  a  community,  when,  as  Daniel  Defoe 
said  in  his  famous  description  of  the  plague 
in  London  in  1665,  "  Men  everywhere  began 
to  despair;  every  heart  failed  them  for  fear; 
people  were  made  desperate  through  the  an- 
guish of  their  souls,  and  the  terror  of  death 
sat  in  the  countenances  of  the  people." 


TUBERCULOSIS 

The  plague  of  old,  however,  with  its  almost 
incredible  mortality,  decimating  the  inhabit- 
ants of  a  country  in  a  short  time,  accom- 
plished its  fatal  work  and  was  done.  The 
present  white  plague,  tuberculosis,  is  never 
done  with  its  insidious  work;  for  numberless 
years  it  has  been  silently,  continuously  and 
unrelentingly  pursuing  its  destructive  course, 
never  remitting  its  deadly  work,  always  reach- 
ing out  for  new  victims,  and  to-day  it  is  the 
most  universal  scourge  of  the  human  race.  It 
is  hardly  conceivable  that  in  any  modern 
country  or  city  of  the  world  any  such  ravages 
of  the  plague  of  old  should  again  occur,  such, 
for  example,  as  happened  in  Marseilles  in 
1720,  when  80,000  people  were  destroyed  by 
it  in  a  short  time,  and  in  London  in  1665,  when 
70,000  inhabitants  perished,  while  Italy  was 
said  to  have  lost  half  its  inhabitants  from  it, 
and  over  one  million  died  in  Germany. 

Neither  do  we  attribute  to  inscrutable 
providence  or  to  nature  the  "  desolation  of 
great  pestilences  "  as  did,  in  their  ignorance, 
the  pious  men  of  old.  Science  has  revealed 
to  us  that  it  was  not  omnipotence  or  nature 
which  afflicted  mankind  with  pestilential  dis- 

2 


ITS   PREVALENCE 

eases,  but  man  himself  through  his  own  igno- 
rance and  uncleanliness.  On  the  contrary 
rather,  we  can  with  greater  justice  affirm  that 
it  was  the  hand  of  a  beneficent  providence 
which  revealed  to  man  the  causes  of  these 
epidemic  diseases  and  their  prevention,  and 
which  brought  to  mankind  through  the  great 
scientist,  Louis  Pasteur,  those  wonderful 
words  of  hope  so  often  quoted :  "  It  is  in  the 
power  of  man  to  cause  all  parasitic  (germ) 
diseases  to  disappear  from  the  world." 

We  now  know  that  the  plague  was  an  in- 
fectious or  germ  disease  like  all  the  other 
great  epidemic  diseases ;  and  it  was  caused  by 
a  germ  known  as  the  "  bacillus  pestis."  We 
also  know  that  the  "  favorable  soil,"  as  we 
call  it,  for  its  ravages,  was  the  uncleanliness 
of  the  medieval  cities,  which  abounded  in  filth 
and  possessed  no  sanitation  in  the  modern 
sense  of  the  word.  When  once  cleanliness  and 
improved  sanitation,  such  as  now  exist  in  all 
modern  cities,  came  into  existence,  the  con- 
ditions for  the  spread  of  the  plague  were  lack- 
ing, and  it  has  now  practically  disappeared 
from  modern  civilized  centers. 


TUBERCULOSIS 

Great  Epidemics  of  the  Middle  Ages 

Such  is  also  the  case  with  other  of  the  great 
epidemics  of  the  middle  ages, — one  after  an- 
other they  have  been  for  the  most  part  elim- 
inated by  modern  methods  of  prevention  and 
sanitation,  such  as  Asiatic  cholera,  yellow 
fever,  typhus  fever,  epidemic  dysentery  and 
others.  Small-pox  was  a  genuine  scourge  to 
mankind  until  the  immortal  Jenner  discovered 
vaccination  in  1796,  and  now  it  only  occurs 
in  cases  where  vaccination  has  been  neglected. 
Leprosy,  which  is  also  an  infectious  disease 
caused  by  a  germ  or  bacillus  very  similar  to 
the  bacillus  of  tuberculosis,  existed  all  over 
Europe  in  the  middle  ages.  In  the  reign  of 
Louis  VIII.  of  France  there  were  2,000  leper 
houses  or  asylums  in  that  country  alone,  while 
in  Great  Britain  such  houses  were  dotted  all 
over  the  land.  At  the  present  time,  as  we 
know,  a  case  of  this  disease  is  a  rare  occur- 
rence among  us.  Better  knowledge  of  the 
causes  of  these  diseases,  cleanliness,  better 
sanitation  and  individual  hygiene  have  con- 
quered them,  and  in  consequence  the  horrors 
of  great  epidemics  have  vanished,  and  one's 
expectancy  of  life  is  increased  from  an  aver- 

4 


ITS   PREVALENCE 

age  of  less  than  fifteen  years  in  1643  to  more 
than  forty  years  at  the  present  time,  and  the 
average  annual  death  rate  throughout  the 
civilized  world  has  been  reduced  from  fifty  or 
more  per  each  1,000  of  the  population  in  the 
seventeenth  and  eighteenth  centuries  to  less 
than  half  that  number  at  the  present  time. 

If  we  could  only  eliminate  all  infectious  or 
contagious  diseases,  what  an  immeasurable 
boon  would  be  conferred  upon  mankind,  and 
upon  generations  yet  unborn !  What  has  been 
accomplished  with  the  single  contagious  dis- 
ease, diphtheria,  by  antitoxin,  which  has  re- 
duced its  mortality  from  about  40  per  cent,  to 
12  per  cent.,  and  even  much  less  if  used  early 
enough,  we  may  confidently  hope  will  be 
accomplished  in  time  with  other  similar 
contagious  diseases.  Towards  this  goal  a 
thousand  investigators  are  working  in  the 
laboratories  of  research  and  in  the  hospital 
clinics. 

Universality  of  Tuberculosis 

Tuberculosis  still  remains,  however,  as  the 
most  destructive  and  universal  disease  which 
afflicts  mankind.  "  In  all  climates,"  says  Dr. 
Ransome,  *'  in  the  North,  and  in  the  South, 

5 


TUBERCULOSIS 

East  and  West,  however  various  the  conditions 
under  which  men  live,  however  much  they  may 
differ  in  race,  in  diet,  and  clothing,  and  in 
habits  of  life,  wherever  human  beings  are  con- 
gregated together  there  tuberculosis  is  to  be 
found."  Although  tuberculosis  exists  among 
all  classes  of  society,  in  the  homes  of  the  rich 
and  in  the  tenements  of  the  poor,  yet  it  is  far 
more  prevalent  among  the  "  poor  and  starv- 
ing," for  misery  and  poverty  are  powerful  pre- 
disposing causes.  It  has,  therefore,  been  well 
called  a  "  social  evil,"  a  "  disease  of  the 
masses,"  for  so  often  is  the  tuberculosis  in- 
dividual a  victim  of  social  conditions  which  it 
is  impossible  for  him  to  overcome ;  the  work- 
man cannot  change  the  bad  air  of  his  work- 
shop, or  live  in  a  model  tenement,  or  always 
obtain  sufficient  and  nutritious  food.  In 
Budapest,  for  example.  Dr.  Korosi  found  that 
consumption  caused  22  per  cent,  of  all  deaths 
among  the  poor,  but  only  16  per  cent,  among 
the  well-to-do.  The  Germans  call  tuberculo- 
sis the  disease  of  the  common  people,  "  Volks- 
krankheit." 

"  Every  other  resident  adult  you  meet  in 
the  streets,"  wrote  Dr.  Oliver  Wendell  Holmes 

6 


ITS    PREVALENCE 

in  1867,  "  is  or  will  be  more  or  less  tuber- 
culous/' And  a  German  authority  has  re- 
cently declared  that  one-half  of  all  deaths  and 
one-half  of  the  sickness  among  adults  in  Ger- 
many can  be  charged  to  tuberculosis.  In  that 
country — Germany — the  present  yearly  mor- 
tality from  this  disease  is  about  100,000.  In 
France  the  yearly  mortality  is  88,000,  and  in 
the  city  of  Paris  it  is  about  9,600,  which  is 
nearly  one-fifth  of  the  whole  number  of 
deaths,  and  three  times  as  many  deaths  as 
from  all  the  other  contagious  diseases  together. 
In  Great  Britain  and  Ireland  the  annual  sacri- 
fice is  75,000,  and  in  the  city  of  London  about 
9,600.  In  1904  in  England  tuberculous  dis- 
eases caused  sixty  deaths  to  sixty-seven 
caused  by  the  combined  chief  acute  infectious 
diseases,  namely: — measles,  whooping  cough, 
diarrhoea  and  dysentery,  typhoid  fever,  diph- 
theria, scarlet  fever,  small  pox  and  typhus 
fever.  In  Austria  the  yearly  mortality  is  over 
80,000;  and  in  the  city  of  Vienna  over  5,000; 
in  Italy  50,000  to  60,000;  and  in  the  United 
States  150,000  or  more,  or  one  death  about 
every  three  minutes.  In  the  State  of  Pennsyl- 
vania it  is  8,000  and  in  New  York  State  over 
14,000   or   ten   per   cent,   of   all   deaths.     In 

7 


TUBERCULOSIS 

Greater  New  York  City  it  is  8,500  and  in  Chi- 
cago 3,600.  Massachusetts  has  a  sacrifice  of 
4,400  and  its  metropolis,  Boston,  1,050.  In 
New  Orleans  it  is  about  900  annually.  As 
great  as  this  mortality  is  it  is  far  less  than  it 
was  fifteen  or  twenty  years  ago  as  we  shall 
later  see.  One  has  only  to  recall  the  conster- 
nation and  terror  caused  by  the  yellow  fever 
epidemic  in  this  city  (New  Orleans),  a  few 
years  ago,  to  remember  that  the  mortality  from 
this  disease  at  that  time  was  hardly  450  deaths. 
And  such  an  epidemic  is  not  likely  to  happen 
for  many  years,  if  ever  again,  while  twice  that 
number  is  sacrificed  not  only  one  year  but  year 
after  year  in  that  city.    ^ 

Tuberculosis    Compared    WitH    Great    Disasters 
and  Wars 

In  the  volcanic  eruption  at  Martinique  30,- 
000  souls  were  destroyed  in  an  instant  and  the 
world  was  appalled  at  the  disaster;  but  this 
number  was  only  one-fifth  of  the  yearly  de- 
struction of  life  from  tuberculosis  in  the 
United  States.  We  think  of  the  terrible  catas- 
trophe from  the  earthquake  in  Sicily,  and  yet 
hardly  more  lives  were  destroyed  than  are  sac- 
rificed every  year  from  tuberculosis  in  the 
United  States,  and  there  may  not  be  another 

8 


ITS    PREVALENCE 

such  destructive  earthquake  for  a  century, 
while  tuberculosis  with  relentless  certainty 
claims  its  great  sacrifice  every  year.  We 
speak  of  the  destruction  of  human  life  from 
war,  but  twice  as  many  died  from  tuberculosis 
in  the  eighteenth  century  as  were  killed  in 
battle  during  the  wars  of  that  period.  In  the 
four  years  of  our  Civil  War  there  were  killed 
and  mortally  wounded  from  155,000  to  161,- 
000,  which  is  not  much  above  the  annual  mor- 
tality from  tuberculosis  in  this  country. 

And  so  one  might  go  on  indefinitely  reciting 
these  ghastly  statistics  for  country  after  coun- 
try and  city  after  city,  until  the  sum  total  of 
annual  deaths  from  tuberculosis  throughout 
the  civilized  world  would  be  found  to  be 
1,000,000  or  more,  or  3,000  each  day;  and  un- 
less conditions  change,  eight  to  ten  millions  of 
people  now  living  in  this  country  are  doomed 
to  death  by  this  plague.  Still,  however,  the 
whole  story  is  not  told,  for  it  has  been  esti- 
mated by  Dr.  Philip  of  Edinburgh,  after  a 
careful  study  of  the  subject,  that  the  ascer- 
tained mortality  in  any  city  can  safely  be 
multiplied  by  ten  in  order  to  represent  approxi- 
mately the  number  of  persons  living  already 
seriously  affected,  and  even  twice  that  figure, 
he  thinks,  would  be  still  below  the  mark.    In 

9 


TUBERCULOSIS 

this  country  (the  United  States),  it  has  been 
estimated  by  good  authority  that  1,500,000 
persons  are  suffering  annually  from  tubercu- 
losis. 

One  is  led  to  inquire  from  all  this  enor- 
mous extent  of  tuberculosis,  why  it  is  that 
anybody  escapes  the  disease?  Indeed,  the 
Germans  have  declared  that  everybody  does 
become  affected  sometime  or  other  in  his  life, 
though  of  course  it  does  not  follow  that  every- 
one who  becomes  infected  with  the  tubercu- 
lous germs  develops  the  active  disease  or  even 
is  ever  aware  that  he  has  had  the  infection. 
Autopsies,  however,  performed  upon  persons 
who  have  died  of  other  diseases  often  show 
evidence  of  tuberculosis  which  was  all  un- 
known to  the  individual  in  his  life-time,  and 
never  produced  any  recognizable  symptoms. 

The  Old  Feeling  of  Hopelessness 

For  countless  years  tuberculosis  has 
been  reaping  this  rich  harvest,  and  so  con- 
tinuously and  silently,  and  yet  so  regularly 
has  the  sickle  fallen  that  the  magnitude  of 
the  crop  was  not  and  still  is  not  realized; 
moreover,  its  victims,  being  ignorant  of 
the  cause  of  the  disease  and  consequently  of 

10 


ITS   PREVALENCE 

its  prevention,  could  only  exclaim,  "  It  is  the 
hand  of  God,  and  we  are  powerless  to  avert 
it."  "  It  is  the  flaming  sword  of  the  destroy- 
ing angel !  "  But  the  beginning  of  the  end 
was  at  hand,  and  after  all  these  years  it  re- 
mained for  Koch  with  his  incomparable  genius 
to  reveal  the  true  cause  of  the  disease  and  to 
open  the  way  to  prevention. 

The  Saddest  Fact  of  All 

In  the  above  portrayal  of  the  prevalence 
and  mortality  of  tuberculosis  the  whole  ex- 
tent of  the  calamity  has  not  yet  been  given, 
and  perhaps  the  saddest  of  all  the  facts  con- 
nected with  tuberculosis  is  yet  to  be  men- 
tioned. The  reader  may  already  have  in  mind 
the  question  which  is  now  to  be  answered: 
"  At  what  age  do  the  majority  of  those  whose 
death  is  caused  by  tuberculosis  die  ?  "  Is  it 
in  infancy,  youth,  manhood  or  old  age?  For 
it  makes  a  vast  difference  in  the  general  and 
economic  welfare  of  the  community  at  what 
age  so  many  deaths  occur  as  those  from  tu- 
t)erculosis.  If  in  infancy  or  childhood,  they 
are  only  potential  factors  in  the  community 
of  workers;  or  if  in  old  age,  their  contribu- 
tion to  the  community  has  been  made.    Alas ! 

II 


TUBERCULOSIS 

tuberculosis  claims  its  victims  in  the  best  years 
of  their  life,  for  it  is  the  sad  fact  that  from 
one-fourth  to  one-third  of  all  deaths  between 
the  ages  of  fifteen  and  thirty-five  or  forty 
years  result  from  this  disease.  In  Germany 
almost  one-half  the  deaths  occurring  between 
fifteen  and  forty  years  of  age  are  from  tuber- 
culosis, reaching  this  proportion  most  nearly 
between  twenty-six  and  thirty  years.  In  Eng- 
land and  Wales,  between  the  ages  of  fifteen 
and  thirty-five  a  little  less  than  one-third  of  all 
deaths  are  due  to  tuberculosis.  In  this  coun- 
try in  the  registration  area,  that  is,  in  those 
states  where  vital  statistics  are  accessible,  of 
all  deaths  occurring  in  1907  nearly  a  third 
(33.2  per  cent.)  between  the  years  of  fifteen 
and  twenty-nine  were  due  to  tuberculosis  in 
some  of  its  forms,  while  the  deaths  from  pneu- 
monia, a  very  prevalent  disease,  were  only 
6.7  per  cent,  during  this  age  period.  For  ma- 
ture manhood  and  womanhood  (30  to  44 
years)  over  one-fourth  (25.6  per  cent.)  of  all 
deaths  were  due  to  tuberculosis,  while  the 
deaths  from  pneumonia  were  only  8.8  per 
cent.  For  the  age  period  of  forty-five  to 
fifty-nine  years,  the  mortality  is  12. i  per  cent., 
for  at  this  period  other  diseases,  such  as  heart 

12 


ITS   PREVALENCE 

and  kidney  disease,  cancer  and  other  so-called 
degenerative  diseases  become  more  frequent. 
It  is  seen,  then,  that  the  majority  of  deaths 
from  tuberculosis  occur  at  the  most  valuable 
period  of  a  person's  life,  the  working,  the  re- 
productive period,  the  age  when  the  life  of  the 
individual  is  of  the  greatest  economic  value  to 
the  community,  and  his  death  of  the  greatest 
economic  loss.    This  fact  is,  perhaps,  the  sad- 
dest of  all  the  grim  facts  connected  with  the 
ravages  of  tuberculosis.     "  The  world  is  for- 
ever   poorer,"    said    Dr.    Wilbur,*   "on    ac- 
count of  the  untimely  death  of  Robert  Louis 
Stevenson,  though  richer  for  the  record  of  his 
brave  fight  against  the  unrelenting   foe,  tu- 
berculosis, that  harried  him  to  the  islands  of 
the  great  '  South  Sea '  he  loved,  and  slew  him 
there.     What  would  have  been  the  value  to 
literature  of  a  few  more  years  of  this  single 
life!  and  how  many  are  now  dying  from  tu- 
berculosis who,  were  they  but  permitted  a  few 
more  years  of  healthful  Hfe,  would  by  their 
works  of  genius  add  immensely  to  the  treas- 
ures of  humanity.    Tuberculosis  kills  men  and 
women  chiefly  in  the  most  active,  most  pro- 
ductive period   of  life,  when  their   work  is 
♦Tuberculosis  in  the  U.  S.  Bureau  of  the  Census. 

13 


TUBERCULOSIS 

worth  the  most  to  themselves,  to  their  fam- 
ines, and  to  the  world." 

Tuberculosis  and  Pneumonia  Compared 

In  comparing  pneumonia,  which  has  been 
referred  to  above,  and  whose  mortality  is 
quite  equal  to  and  sometimes  a  little  above 
that  of  tuberculosis,  with  the  latter  disease,  we 
find  this  startling  difference:  that  whereas 
pneumonia  destroys  the  majority  of  its  vic- 
tims at  the  two  extremes  of  life, — ^the  young 
child  before  it  becomes  economically  and  so- 
cially valuable  and  before  it  has  received  a 
more  or  less  expensive  training  for  its  life 
work,  and  the  old  person  who  has  completed 
his  work  and  made  his  contribution  to  so- 
ciety,— tuberculosis,  on  the  other  hand,  gathers 
its  harvest  between  these  extremes :  it  "  loves 
a  shining  mark."  It  clutches  in  its  relentless 
grasp  the  young  man  just  established  in  his 
profession  or  trade,  the  young  mother  in  her 
family,  the  father  upon  whose  working  ability 
the  wife  and  family  depend,  the  young  col- 
lege graduate  with  anticipations  of  high 
achievement,  or  it  cuts  off  the  genius  who  has 
already  become  famous,  in  the  midst  of  his 
career.     So  it  happened  to  the  German  poet 

14 


ITS   PREVALENCE 

Schiller,  and  to  Keats,  the  sweet  English 
singer;  to  the  nature-loving  Thoreau,  and  to 
the  musicians  Chopin  and  Weber.  It  is  in 
adult  life  that  we  accomplish  our  main  life's 
work.  As  Dr.  Osier  tells  us,  our  principal 
creative  work  and  achievements  are  completed 
at  forty  years  of  age.  It  is  just  at  this  in- 
finitely valuable  period  that  tuberculosis  does 
its  fatal  work,  and  that  is  what  makes  the 
disease  so  dreaded  and  so  destructive. 

Economic  Loss  From  Tuberculosis 

Consider  for  a  moment,  in  terms  of  dollars 
and  cents,  the  prodigious  economic  loss  en- 
tailed upon  the  community  by  tuberculosis. 
Ill  the  United  States  it  has  been  esti- 
mated that  the  money  loss  from  tuber- 
culosis is  $1,235,000,000  a  year;  in  France, 
$200,000,000  a  year ;  in  Canada  Dr.  Richer  es- 
timates the  loss  at  $72,000,000,  and  in  New 
York  City  Dr.  Biggs  has  estimated  that  the 
annual  loss  to  the  city  from  tuberculosis  is 
$23,000,000.  The  total  annual  loss  to  the  State 
of  Illinois  after  a  very  fair  and  conservative 
estimate  based  upon  statistics  has  been  placed 
at  $36,551,000.  England,  in  fifteen  years,  has 
expended  $600,000,000  in  combating  tubercu- 

15 


TUBERCULOSIS 

losis  and  has  saved  876,581  lives  thereby,  or 
in  round  numbers  $685  apiece.  Dr.  News- 
holme,  a  health  officer  of  England,  estimates 
that  in  Wales  alone  by  the  abolition  of  tuber- 
culosis in  that  country  not  far  from  $50,000,- 
000  annually  could  be  saved.  "  And  this,"  he 
says,  "  makes  no  allowance  for  the  loss  sus- 
tained by  protracted  sickness,  nor  for  the  fur- 
ther loss  from  premature  death  of  women 
from  the  same  cause." 

Mr.  Hoffman,  the  statistician  of  the  Pru- 
dential Insurance  Company,  says  that  the  an- 
nual cost  of  deaths  from  tuberculosis  to  that 
company,  on  a  basis  of  three  years'  experience, 
is  $800,000.  Cornet,  the  German  authority, 
estimates  that  the  deaths  from  consumption 
in  Prussia,  if  we  reckon  only  one  year  of  in- 
validism when  the  sufferer  cannot  work,  cost 
that  country  $23,000,000  annually,  and  this 
does  not  take  into  account  the  added  years  of 
life  and  remunerative  employment  which 
would  follow  if  consumption  were  banished. 
One  can,  to  a  degree,  understand  how  such 
enormous  losses  occur  if  he  considers  the 
amount  expended  upon  education  and  prepa- 
ration for  work;  the  value  of  the  workman 
when  he  has  been  prepared  for  his  life's  work, 

16 


ITS   PREVALENCE 

which,  at  a  very  conservative  calculation,  has 
been  estimated  to  be  $1,500,  and  the  value  of 
his  work,  his  support,  care  and  nursing  during 
the  period  before  his  death  when  he  is  un- 
able to  work;  and  then  there  must  be  added 
to  this,  in  so  many  cases,  the  support  of  the 
family  left  behind,  who  have  been  deprived  of 
their  bread-winner. 

Dr.  Newsholme  thus  admirably  states  the 
economic  value  of  lives  lost  during  their  best 
working  period :  "  Each  child,"  he  says,  "  un- 
til he  is  able  to  support  himself,  is  having  ex- 
pended upon  him,  time,  money  and  effort 
which  may  be  regarded  as  so  much  capital 
invested  with  a  prospect  of  future  returns. 
If  he  dies  in  infancy,  the  measurable  loss  is 
much  less  than  if  the  death  is  postponed  until 
the  age  of  fifteen.  Between  the  ages  of  fif- 
teen and  twenty,  it  is  probably  exceptional 
for  the  earnings  to  more  than  balance  per- 
sonal expenditure,  and,  if  this  is  so,  all  deaths 
up  to  the  age  of  twenty  may  be  regarded  as 
involving  a  serious  loss  of  capital  expendi- 
ture. During  the  next  five  years,  a  large  pro- 
portion of  the  population  marry  and  thus  in- 
cur new  obligations  before  the  balance  against 
them  can  possibly  have  been  paid  off.     It  is 

17 


TUBERCULOSIS 

during  the  following  thirty  or  forty  years  that 
he  can  hope  to  pay  back  the  value  of  his  own 
earlier  maintenance  by  personal  savings  and 
by  investing  capital  in  the  formation  of  a 
home  and  the  upbringing  of  a  family  in  his 
turn.  Each  family  represents  in  this  respect 
an  investment  on  the  installment  system,  and 
the  only  hope  of  completing  the  investment 
and  leaving  no  debt  for  the  survivors  to  re- 
deem or  owe  to  the  community,  is  for  the 
worker  to  live  and  remain  able  to  work  until 
all  his  children  are  able  to  earn  their  liveli- 
hood, and  until  his  wife  and  himself  can  main- 
tain themselves  in  their  old  age.  This  can 
only  be  realized  when  the  worker  is  not  cut 
down  by  illness  or  killed  by  disease  or  acci- 
dent. Hence  the  immense  economic  signifi- 
cance of  the  fact  that  among  men  nine  out  of 
every  ten  deaths  from  tuberculosis  occur  be- 
tween the  ages  of  fifteen  to  sixty-five." 

In  the  above  consideration  we  have  been 
attempting  to  estimate  the  loss  from  tubercu- 
losis in  terms  of  economic  value,  in  money, 
but  who  can  estimate  the  suffering,  the  pov- 
erty, the  sorrow,  the  blighted  hopes,  the  loss 
of  personal  influence,  the  severed  friendships 
entailed  by  this  ever-present,  cruel  disease, — 

i8 


ITS  PREVALENCE 

a  disease  whose  cause  is  now  known  and 
which  is  preventable.  Thirty  years  ago,  the 
world  first  learned  this  incomparably  pre- 
cious fact,  and  this  dark  picture  of  the  awful 
ravages  of  tuberculosis  was  illumined  by  the 
light  of  knowledge  and  hope.  Again  may 
Louis  Pasteur's  great  saying  be  repeated: 
"  It  is  in  the  power  of  man  to  cause  all  para- 
sitic (germ)  diseases  to  disappear  from  the 
world."  It  is  in  the  power  of  man  to  banish 
tuberculosis. 

Effect  Upon  Different  Races 

Tuberculosis  does  not  afflict  all  races  or  the 
sexes  equally.  Certain  races  seem  to  be  more 
susceptible  to  the  disease  than  others.  In 
some  cases  it  may  be  a  true  racial  suscepti- 
bility, while  in  others  it  may  be  the  conditions 
under  which  the  race  lives  and  their  personal 
habits. 

Thus,  the  colored  race  in  the  United  States 
has  at  the  present  time  at  least  four  times  the 
mortality  as  the  white  race,  whereas  before 
the  Civil  War  the  disease  was  rare  among  the 
colored  population.  As  slaves  they  lived  a 
healthy  outdoor  life,  in  the  country,  and  were 
well  fed,  clothed  and  lodged,  for  they  were 

19 


TUBERCULOSIS 

valuable  property  and  it  was  for  the  com- 
mercial interest  of  their  owners  to  take  good 
care  of  them.  Since  emancipation  they  have 
had  no  one  to  overlook,  with  such  interest, 
their  physical  well-being;  they  have  flocked 
to  the  cities,  have  had  more  confined  work 
in  factories  and  workshops,  with  long  hours 
of  work,  poor  pay,  and  often  insufficient 
food;  they  were  ignorant  of  the  principles  of 
sanitation,  and  have  had  access  to  cheap 
liquor.  Environment,  ignorance  and  the 
abuse  of  alcohol  would  seem  to  be  the  impor- 
tant factors  in  producing  this  high  mortality 
from  tuberculosis  in  this  race. 

Again,  tuberculosis  is  more  prevalent  in  the 
Irish  than  in  any  other  European  race.  This 
is  especially  true  with  this  race  in  the  United 
States.  Dr.  Flickl  thinks  this  is  due  to  a 
racial  susceptibility.  Probably  also  the 
greater  confinement  indoors  in  this  country, 
and  the  addiction  to  alcoholic  liquors  of  this 
race  play  an  important  part. 

The  Indian  when  brought  in  contact  with 
civilization  shows  a  large  mortality  from  tu- 
berculosis. This  is  ascribed,  and  probably  with 
truth,  to  the  *'  disastrous  effect  of  civilization 
upon  a  savage  race."     How  true  it  is  that  it 

20 


ITS  PREVALENCE 

requires  both  education  and  experience  to 
avail  one's  self  of  the  benefits  of  civilization 
and  avoid  its  evils. 

In  this  country  the  Bohemian,  the  Scandi- 
navian, the  French,  the  German,  the  Scot, 
and  the  Canadian  come  next  respectively  in 
order  of  mortality,  while  the  Italian  and  the 
Jew  are  lowest  in  the  scale.  Throughout  the 
world  the  Jews  have  a  comparatively  low 
death  rate  from  tuberculosis.  This  has  been 
attributed  to  a  genuine  racial  resisting  power 
to  this  disease  and  also  to  their  well-known 
temperance,  particularly  in  the  use  of  alco- 
holic drinks. 

Sex  and  Tuberculosis 

With  regard  to  the  influence  of  sex  upon 
the  mortality  from  tuberculosis,  at  the  pres- 
ent time  the  male  mortality  is  somewhat  in 
excess  of  that  of  the  female.  In  earlier  years, 
however,  both  in  England  and  in  the  State  of 
Massachusetts,  where  alone  statistics  upon 
this  point  were  at  hand,  the  reverse  was  the 
fact.  One  of  the  reasons  for  this  change  may 
be  the  increased  outdoor  life  which  has  be- 
come popular  among  women  of  late  years,  and 
another,  the  general  movement  now  going  on 

21 


TUBERCULOSIS 

throughout  the  civilized  world  for  the  physi- 
cal and  social  amelioration  of  the  condition  of 
working-women.  Furthermore,  the  enormous 
increase  in  manufacturing,  and  the  consequent 
congestion  of  population  has  added  to  the 
risks  to  life  and  health  of  the  male  laborer. 
The  early  simple  life  was  as  conducive  to 
physical  well-being  as  to  moral  and  spiritual 
health. 


22 


II.    WHAT    IS    TUBERCULOSIS?     ITS 
NATURE  AND   CAUSE 

^O^^^  UBERCULOSIS  is  a  disease 
M  C^\  which  may  affect  any  part  of  the 
B  I    body  and  is  characterized  by  the 

^^^^^F  formation  of  "  tubercles  "  which 
are  at  first  tiny  bodies  or  nodules 
detected  by  the  microscope  and  which  increase 
in  size  as  the  disease  advances.  These  tu- 
bercles destroy  the  tissues  in  whatever  part  of 
the  body  they  occur,  and,  if  in  the  lungs, 
where  they  are  most  commonly  found,  their 
tendency  is  to  ever  extend  their  field  of  de- 
struction like  the  march  of  an  invading  army. 

Description  and  Location 

Different  names  are  often  given  to  tubercu- 
losis as  it  affects  different  parts  of  the  body ; 
thus,  tuberculosis  of  the  hip  is  called  "  hip 
joint  disease " ;  tuberculosis  of  the  knee  or 
ankle,  "  white  swelling  " ;  of  the  skin,  *'  lu- 
pus " ;  and  of  the  glands  of  the  neck,  "  scrof- 
ula."    In  other  cases  we  simply  speak  of  tu- 

23 


TUBERCULOSIS 

berculosis  as  of  this  or  that  part  of  the  body, 
as  tuberculosis  of  the  bones,  the  kidneys, 
throat,  bowels,  etc.  Tuberculosis  of  the 
lungs,  called  "  consumption "  or  "  phthisis," 
is  the  most  common  form  of  the  disease, 
nearly  nine-tenths  of  all  tuberculosis  being 
that  of  the  lungs. 

It  is  in  fact  a  very  old  disease,  and  like 
other  infectious  diseases,  nobody  knows  how 
or  when  it  had  its  origin.  Somehow  it  was 
evolved  in  the  process  of  civilization  like 
many  other  evils,  and  is  one  of  the  penalties 
we  have  to  pay  for  the  many  good  things 
civilization  has  brought  us.  "  It  is  a  disease 
of  all  times,  of  all  countries,  and  of  all  races." 
Hippocrates,  a  renowned  Greek  physician  who 
lived  about  400  b.  c,  gave  a  very  excellent 
description  of  the  disease,  and  from  that  time 
to  the  present  medical  writers  have  recog- 
nized and  described  it. 

The  cause  of  tuberculosis  was  ascribed  to 
various  influences:  thus,  Hippocrates  thought 
it  was  due  to  some  poison  in  the  air  wafted  by 
the  winds  from  one  place  to  another.  Other 
old  writers  upon  the  subject  ascribed  it  to  the 
use  of  chimneys  in  houses,  to  smoke  from 
wicks  of  candles,  excess  of  animal  food,  and 

24 


ITS    NATURE   AND    CAUSE 

to  tight  lacing  and  stays.  A  keen  and  wise 
observer  was  he  who  ascribed  it  to  this  lat- 
ter cause.  It  seems  almost  startling  that  the 
world  should  have  remained  all  these  hun- 
dreds of  years  in  ignorance  of  its  cause  until 
a  man  recently  living,  finally  in  the  fullness 
of  time,  discovered  the  true  cause  and  proved 
it  so  perfectly  and  completely  that  no  one  has 
ever  been  able  to  disprove  it. 

Dr.  Koch's  Discovery 

It  was  in  1882  that  Dr.  Robert  Koch  made 
this  marvelous  discovery;  the  hour  and  the 
man  had  arrived  and  the  great  light  shone. 
The  blessings  which  this  discovery  has  con- 
ferred upon  humanity,  and  will  continue  to 
bestow  as  time  goes  on,  are  almost  incalcula- 
ble, for  all  our  direct  measures  for  the  pre- 
vention and  control  of  tuberculosis  depend 
upon  the  knowledge  of  its  cause. 

The  manner  and  method  of  Dr.  Koch  In 
making  this  discovery  are  of  intense  interest. 
Villemin,  a  French  investigator,  had  success- 
fully demonstrated  in  1865,  by  experiments 
upon  animals,  that  tuberculosis  was  infec- 
tious, or,  to  use  a  better  term,  "  communica- 

25 


TUBERCULOSIS 

ble,"  but  he  did  not  discover  the  cause  of  the 
infection.  Many  others  at  earHer  dates  had 
also  beHeved  in  the  infectious  nature  of  the 
disease  and  stringent  laws  were  enacted  re- 
garding its  isolation,  and  disinfection:  thus, 
in  1638  Lazarus  Riverius,  who  wrote  a  book 
on  medicine  called  "  Practice  of  Physik," 
says :  "  Moreover,  there  are  causes  of  tuber- 
culosis of  the  lungs,  as  contagion,  which  is 
the  chiefest,  for  this  disease  is  so  infectious 
that  we  may  observe  women  to  be  infected  by 
their  husbands,  and  men  by  their  wives;  and 
all  their  children  to  die  of  the  same,  not  only 
from  heredity,  but  from  the  company  of  him 
that  was  first  affected." 

By  means  of  modern  bacteriological 
methods,  the  improved  compound  microscope 
and  his  own  genius.  Dr.  Koch,  after  many 
unsuccessful  attempts,  finally  demonstrated 
the  microscopic  germ  called  the  *'  tubercle 
bacillus,"  which  is  a  rod-like  structure,  a  mi- 
croscopic fungus,  so  small  that  it  requires 
from  eight  to  twelve  thousand  placed  end  to 
end  to  measure  an  inch,  and  900  of  them  can 
be  placed  on  the  point  of  a  small  sewing 
needle,  or  4,000,000  on  a  postage  stamp.  How 
marvelous    the   delicacy   and   power    of   the 

26 


ITS    NATURE   AND    CAUSE 

modern  microscope  which  will  enable  us 
easily  to  detect  this  infinitesimally  tiny  germ! 
In  the  first  place,  Dr.  Koch,  by  methods  of 
staining  and  the  use  of  the  high-powered 
compound  microscope,  found  this  tubercle 
bacillus  in  every  case  of  tuberculosis,  in  what- 
ever part  of  the  body  the  disease  existed,  and 
in  the  sputum  of  consumptives.  This  he  did 
by  the  examination  of  the  diseased  tissues. 
He  never  found  it  in  other  diseases  or  in 
healthy  tissues.  He  next,  by  means  of  the 
methods  bacteriologists  employ  for  cultivat- 
ing germs,  very  like  the  growing  of  crops  on 
suitable  soil,  grew  a  crop  of  the  tubercle  ba- 
cilli upon  what  might  be  called  germ  soil,  the 
scientific  name  of  which  is  "media."  The 
next  step,  the  most  important  one  of  all,  was 
to  prove  that  these  artificially  grown  bacilli, 
freed,  by  a  series  of  transplantations,  from  all 
products  of  disease,  and  all  other  germs,  a 
"  pure  culture,"  as  it  is  called,  would  produce 
the  same  disease,  tuberculosis,  whence  they 
came.  For  this  purpose,  he  inoculated  a 
large  number  of  guinea-pigs,  rabbits,  and  cats 
with  this  "  pure  culture  "  of  tubercle  bacilli, 
and  also  sprayed  a  solution  containing  the  ba- 
cilli   into    a    large   box    containing    rabbits, 

27 


TUBERCULOSIS 

guinea-pigs,  rats  and  mice,  and  in  every  case 
he  produced  tuberculosis  exactly  like  the 
original  disease  from  which  the  germs  were 
first  obtained.  Furthermore,  he  injected  into 
hundreds  of  guinea-pigs  and  rabbits  various 
substances,  diseased  tissues  caused  by  other 
diseases,  etc.,  and  never  once  produced  tuber- 
culosis. This  famous  demonstration  was  re- 
peated again  and  again  by  other  investigators 
and  was  always  corroborated. 

Value  of  Animal  Experimentation 

We  hear  much  in  these  days  of  the  evils 
of  vivisection  and  experiments  upon  animals, 
but  when  one  considers  the  inestimable  boon 
conferred  upon  mankind  by  the  discovery  of 
the  tubercle  bacillus,  was  not  the  sacrifice  of 
a  few  animals  a  thousand  times  justified? 
"  Everything  that  has  a  direct  bearing  on  the 
prevention  of  tuberculosis,"  says  Dr.  E.  L. 
Trudeau,  one  of  the  foremost  pioneers  and 
investigators  in  the  great  movement  against 
tuberculosis,  "  everything  that  has  changed 
mankind's  attitude  towards  it  from  one  of 
apathy  and  hopelessness  when  the  infectious 
agent  which  produces  tuberculosis  was  un- 
known and  the  disease  was  thought  to  be  ki- 

28 


ITS    NATURE   AND    CAUSE 

herited  and  always  fatal,  to  the  growing  hope 
of  its  ultimate  conquest  ...  we  owe  to 
animal  experimentation." 

The  new  light  had  at  last  arisen  after  so 
many  centuries  of  groping  in  the  dark,  the 
true  cause  of  tuberculosis  was  at  last  re- 
vealed, and  science  had  triumphed.  All 
honor  to  the  great  investigator  who  after 
years  of  patient  and  discouraging  labor  in  his 
laboratory  had  at  last  succeeded!  We  extol 
the  great  captains  of  war  who  have  waged 
successful  campaigns.  How  much  more  should 
we  esteem  those  great  investigators,  like 
Pasteur  and  Koch,  whose  victories  mean  not 
suffering  and  death,  but  the  preservation  of 
life  and  the  conquering  of  disease. 

Nature  of  the  Tubercle  Bacillus 

In  investigating  the  nature  of  the  tubercle 
bacillus,  it  was  found  that  it  did  not  grow  and 
multiply  outside  of  the  body,  but  that  it  would 
live  a  considerable  time,  for  weeks  or  even 
several  months,  in  dark,  damp,  dirty  places; 
that  it  was  readily  and  quickly  destroyed  by 
sunlight,  and  that  daylight  and  fresh  air 
would,  after  a  while,  kill  it,  or  at  least  render 
it  inactive ;  that  a  high  temperature,  that  of 

29 


TUBERCULOSIS 

boiling  water,  for  instance,  and  certain  disin- 
fectants would  also  destroy  it ;  but  that  it  sur- 
vived a  freezing  temperature. 

Having  discovered  the  cause  of  tuberculo- 
sis, the  next  inquiry  was,  how  was  this  germ, 
the  tubercle  bacillus,  conveyed,  or,  in  other 
words,  how  was  tuberculosis  caught?  Not 
by  the  mere  contact  with  a  person  who  is  suf- 
fering from  the  disease,  as  seems  to  be  the 
case  in  the  acute  infectious  diseases,  such  as 
small-pox  or  scarlet  fever;  nor  by  the  breath, 
as  is  sometimes  erroneously  supposed,  but  by 
the  only  means  by  which  the  bacilli  can  escape 
from  a  consumptive  person,  namely,  through 
the  expectoration,  or  in  coughing,  when  tiny 
drops  of  sputum  are  thrown  out,  which  ex- 
periments have  proved  can  contain  the  bacilli. 

Dry  Sputum  Alone  Dangerous 

As  long,  however,  as  the  tuberculous  ex- 
pectoration is  mixed  with  the  moist  secretions, 
is  wet,  the  bacilli  are  imprisoned  in  this  moist- 
ure and  cannot  escape.  It  is  only  when  the 
moist  secretions,  the  sputum,  becomes  dry 
that  the  germs  are  set  free  and  mix  with  the 
dust  in  the  air;  then  the  danger  begins.  From 
the  foregoing  it  is  obvious,  then,  that  a  con- 

30 


ITS    NATURE   AND   CAUSE 

sumptive  who  does  not  have  any  expectora- 
tion, as  is  not  infrequently  the  case  in  the 
very  early  stages  of  the  disease,  can  give  out 
no  bacilli  and  consequently  is  not  a  source  of 
any  danger.  It  also  follows  that  when  all  the 
expectoration  is  destroyed  before  it  becomes 
dry,  there  is  again  no  danger,  and  also  when 
the  consumptive  holds  a  cloth  or  some  article 
before  his  mouth  when  coughing,  there  are 
no  tubercle  bacilli  thrown  out  into  the  air. 

How  to  Control  the  Disease 

The  way  of  the  prevention  and  control  of 
the  disease  would  seem  plain  and  easy,  or  it 
would  be  easy  if  we  could  always  control  the 
consumptive.  This,  however,  alas !  is  easier 
said  than  done,  for  we  have  to  deal  with  all 
sorts  and  conditions  of  consumptives,  some 
ignorant,  some  careless,  some  wilful,  and  some 
who  do  not  know  that  they  are  suffering  from 
the  disease.  It  is  only  by  education,  constant 
watchfulness,  the  prevention  of  indiscrimi- 
nate spitting,  and  in  many  cases  by  the  removal 
to  a  hospital,  and  thus  isolating  the  consump- 
tive, that  we  can  ever  hope  to  control  the 
disease.  It  can  be  done,  however,  and  great 
progress  has  already  been  made.     It  all  de- 

31 


TUBERCULOSIS 

pends  upon  the  energy,  determination,  and 
contribution  of  money,  effort  and  time  which 
the  people  are  willing  to  make. 

How  many  germs  must  enter  one^s  body  be- 
fore tuberculosis  is  produced  we  do  not  know. 
Much,  undoubtedly,  depends  upon  what  we 
call  the  susceptibility  of  the  individual.  So 
far  as  we  can  judge  from  experience,  it  takes 
a  good  many  germs  and  a  considerable  time 
to  become  infected.  In  many  cases  it  is  be- 
lieved that  the  bacilli  remain  in  the  body  for 
years  all  unknown,  and  without  causing  any 
symptoms,  and  then,  upon  a  favorable  occa- 
sion, when  the  individual,  from  some  depress- 
ing influence,  like  over-work,  some  disease, 
such  as  an  attack  of  influenza,  some  excess, 
etc.,  becomes  susceptible,  the  latent  bacilli 
spring  into  life  and  active  tuberculosis  re- 
sults. It  is  now  a  generally  accepted  theory 
that  most  human  beings  contract  the  infection 
of  tuberculosis  in  childhood. 

A  "House  Disease" 

Observation,  again,  has  taught  us  that  the 
disease  for  the  most  part  is  contracted  by 
long  and  close  intimacy  with  a  person  suffer- 
ing from  it,  and  who  does  not  properly  de- 
stroy his  sputum  before  it  becomes  dry; 
hence,  we  call  consumption  a  "  house  disease," 

32 


ITS    NATURE   AND    CAUSE 

for  it  so  often  happens  that  when  one  mem- 
ber of  a  household  is  suffering  from  the  dis- 
ease, others  in  the  family  contract  it.  If  it 
is  the  father  or  mother  who  has  tuberculo- 
sis, some  of  the  children  are  often  found  to 
be  suffering  from  it.  Again,  it  is  not  of  in- 
frequent occurrence  that  a  workman  who,  day- 
after  day,  pursues  his  occupation  in  close 
intimacy  with  a  fellow-workman  who  is  a 
consumptive  and  who  is  careless  in  the  dis- 
posal  of  his  sputum,   contracts  tuberculosis. 

A  momentary  exposure  to  an  atmosphere 
containing  bacilli  is  probably  not  a  source  of 
danger.  There  must  be  a  longer  exposure 
than  that.  There  is  an  erroneous  impression 
that  the  tubercle  bacilli  are  so  universally  dis- 
tributed that  we  are  exposed  to  them  every 
day  and  everywhere,  as  a  lawyer  once  re- 
marked to  a  physician  on  the  witness  stand: 
"  I  suppose  there  are  germs  of  tuberculosis 
all  about  this  court  room."  On  the  contrary, 
researches  upon  this  point  all  tend  towards  the 
conclusion  that  in  rooms  which  are  clean  and 
in  which  the  atmosphere  is  quiet,  there  are 
jio  bacilli  floating  about. 

Why,  then,  one  might  pertinently  ask,  do 
we  require  such  stringent  m^easures  against 

33 


TUBERCULOSIS 

indiscriminate  spitting  upon  the  sidewalks  and 
in  public  places  and  vehicles?  Because,  if 
everybody  expectorates  upon  the  sidewalk 
there  is  sure  to  be  someone  who  is  suffering 
from  tuberculosis,  and  the  passer-by  can 
easily  carry  some  of  the  infected  sputum  into 
his  house  on  his  garments  or  his  footwear. 
Children  play  upon  the  floor,  babies  creep 
on  the  floor,  and  they  frequently  put  their 
fingers  in  their  mouths;  thus  they  may  be- 
come infected. 

How  Bacilli  Enter  the  Body 

The  next  question,  and  one  that  is  not  yet 
settled,  is,  through  what  channels  the  bacilli 
enter  the  body:  do  we  breathe  in  the  germs, 
take  them  into  the  digestive  tract  through  con- 
taminated food,  or  drink  them  in  infected 
milk?  So  far  as  experience  and  experiment 
permit  us  to  say,  the  bacilli  gain  entrance  into 
the  body  through  (i)  inhalation,  breathing 
them  into  the  lungs,  and  through  (2)  in- 
gestion, taking  them  into  the  stomach  and  in- 
testinal tract  with  the  food.  Some  authorities 
think  one  way  is  the  more  frequent  and  some 
the  other.  In  the  author's  opinion  the  ex- 
perimental evidence  seems  to  be  greatly  in 

34 


ITS    NATURE   AND   CAUSE 

favor  of  the  inhalation  method  of  infection. 
Practically  it  makes  but  little  difference  which 
is  the  more  common  way  by  which  the  bacilli 
enter  the  body,  for  if  the  tuberculous  sputum 
is  destroyed  before  it  becomes  dry  and  gets 
into  the  atmosphere  there  can  be  no  danger 
of  infection  by  either  way.  There  is  also  a 
third  channel  through  which  the  bacilli  may 
enter  the  body,  and  that  is  through  the  skin 
when  it  is  broken,  or  through  a  wound.  This 
is  called  the  inoculation  method.  A  person 
with  a  wound  upon  his  finger,  for  example, 
may  handle  tuberculous  tissue  or  sputum  and 
through  the  wound  become  infected  with  the 
disease.  This  form  of  infection  happens  so 
rarely,  however,  that  it  may  be  disregarded  in 
the  consideration  of  the  subject. 

Infected  Milk 

Milk  has  been  mentioned  as  a  source  of  in- 
fection, for  when  it  is  obtained  from  tuber- 
culous cows  it  is  not  infrequently  found  to  con- 
tain the  bovine  tubercle  bacilli.  It  was  formerly 
supposed  that  milk  was  a  common  carrier  of 
infection,  and  that  children  whose  diet  con- 
sists principally  of  this  substance  often  be- 
come infected  in  this  way.     Many  health  au- 

35 


TUBERCULOSIS 

thorities  in  cities  required  dairy  herds  to  be 
**  tested,"  as  it  is  called,  by  tuberculin,  which 
almost  invariably  proved  the  presence  of  tuber- 
culosis when  it  existed.  At  the  present  time 
there  is  much  difference  of  opinion  among 
investigators  as  to  whether  or  not  the  kind  of 
tuberculosis  from  which  cows  and  other  ani- 
mals suffer  can  be  conveyed  to  human  beings. 
Koch,  the  discoverer  of  the  human  bacillus, 
has,  from  his  investigations,  concluded  that  it 
is  an  uncommon  occurrence  for  the  "  bovine 
bacillus,"  the  germ  which  produces  tubercu- 
losis in  cows  and  cattle,  to  produce  the  disease 
in  man.  Other  able  investigators  have  come 
to  a  different  conclusion,  and  a  few  believe 
that  milk  containing  the  ''  bovine  bacillus " 
is  the  principal  source  of  infection.  So  the 
question  remains  unsettled  at  the  present  time. 
It  is  generally  believed,  however,  that  gland 
tuberculosis  in  children,  called  scrofula,  is 
caused  by  the  bovine  bacillus. 

So  long,  however,  as  the  possibility  exists 
of  infection  through  milk,  the  only  safe 
method  to  pursue  is  to  continue  the  precau- 
tions already  adopted,  of  testing  all  cows  peri- 
odically whose  milk  is  used  for  domestic  pur- 
poses, and  to  maintain  a  rigid  milk  inspec- 

36 


ITS   NATURE   AND   CAUSE 

tion.  At  the  great  International  Congress  on 
Tuberculosis  held  in  1908  in  Washington,  the 
following  resolution  upon  this  point  was 
adopted :  "  Preventive  measures  must  be  con- 
tinued against  bovine  tuberculosis,  and  the 
possibility  of  the  propagation  of  this  to  man 
should  be  recognized." 


37 


III.  TUBERCULOSIS  A  CONTAGIOUS 
OR  INFECTIOUS  DISEASE:  WHAT 
THIS  MEANS 

What  is  a  Contagious  or  Infectious  Disease? 

OTH  of  the  terms  contagious  and 
infectious  are  commonly  used 
interchangeably  and  practically 
mean  the  same  thing.  They  are 
applied  to  diseases  which  are  con- 
veyed from  one  person  to  another  by  means 
of  some  substance  or  germ,  known  or  un- 
known, either  directly  by  contact  with  the 
person  or  germ  or  through  the  medium  of 
something  which  has  become  infected  by  the 
individual  who  is  suffering  from  the  con- 
tagious disease,  whatever  it  may  be.  Thus, 
for  example,  clothing,  the  furnishings  of  a 
room,  or  some  article  used  by  the  infected 
person,  may  receive  the  infectious  material  or 
germs  and  anyone  who  handles  these  articles 
may  in  turn  contract  the  disease.  Small-pox 
is  a  familiar  example  of  this  form  of  con- 

38 


A    CONTAGIOUS    DISEASE 

tagion.  Mosquitoes,  flies,  and  other  in- 
sects may  also  be  the  medium  through  which 
contagious  or  infectious  diseases  are  con- 
veyed :  thus,  a  pecuHar  kind  of  mosquito  car- 
ries the  infectious  material  of  yellow  fever  in 
its  body,  and  flies  carry  the  germs  of  typhoid 
fever  and  other  diseases. 

Acute   Infectious   Diseases 

When  one  speaks  ordinarily  of  infectious 
or  contagious  diseases  he  has  in  mind  those 
which  are  acute  and  occur  in  a  few  days 
after  an  exposure  to  them,  such  as  scarlet 
fever,  measles,  whooping  cough,  or  diph- 
theria. The  relation  of  cause  and  effect  is 
so  obvious  and  the  effect  follows  so  closely 
upon  the  cause,  that  one  is  impressed  with 
the  fact,  and,  quite  naturally,  when  he  hears 
the  word  contagion,  thinks  only  of  this  acute 
form  of  infection.  The  acutely  contagious 
diseases  may  be  contracted  by  a  short  expo- 
sure to  them :  thus,  for  example,  a  child  who 
comes  in  contact  with  another  who  is  suffer- 
ing from  scarlet  fever  or  measles,  even  though 
it  may  be  for  a  very  short  time,  often  contracts 
the  disease  if  it  is  in  a  susceptible  condition, 
or  has  not  gained  immunity  from  a  previous 

39 


TUBERCULOSIS 

attack.  We  therefore  isolate  persons  who 
have  acute  infectious  diseases  for  the  protec- 
tion of  others,  and  when  they  have  recovered 
we  disinfect  the  sick  room  for  fear  that  in- 
fectious germs  may  be  lurking  about  the  fur- 
niture or  walls  of  the  room. 

With  many,  if  not  most  of  the  acute  in- 
fectious diseases,  we  do  not  know  how  the 
infection  is  given  oif  or  how  it  enters  the 
body  of  another  person.  Consequently,  we 
take  great  care  to  avoid  those  suffering  from 
such  diseases.  Ignorance  of  the  cause  of  evil 
always  makes  one  more  apprehensive  regard- 
ing it.  We  fear,  often  unduly,  the  enemy 
whose  method  of  attack  and  of  inflicting  in- 
jury we  are  ignorant  of. 

Chronic  Contagious  Diseases 

Besides  the  acute  contagious  disease,  there 
are  also  chronically  contagious  ones,  of  which 
leprosy  and  tuberculosis  are  the  best  examples. 
Such  diseases,  although  contagious  or  infec- 
tious, are  not  conveyed  through  a  momentary 
exposure  to  them;  but  is  only  by  long  con- 
tact or  intimate,  continued  association  with 
individuals  suffering  from  them  that  we  be- 
come infected,  and  then,  probably,  only  when 

40 


A   CONTAGIOUS   DISEASE 

we  are  in  a  so-called  susceptible  condition. 
We  see,  then,  that  there  is  a  very  great  differ- 
ence between  the  two  kinds  of  contagious  dis- 
eases— the  acute  and  the  chronic.  There  is 
very  little,  if  any,  fear  that  we  shall  contract 
the  latter — the  chronic  contagious  diseases — 
by  a  momentary  exposure  to  their  infection. 

In  the  case  of  tuberculosis,  we  are  not  in 
Ignorance  of  the  way  in  which  the  infection 
is  given  off  or  how  it  is  conveyed  to  another, 
as  is  the  case  with  most  of  the  acute  infec- 
tious diseases.  We  know  that  the  sputum  is 
the  only  way  by  which  a  tuberculous  person 
can  infect  another,  and  then  only  when  it  is 
allowed  to  become  dry  before  it  is  destroyed, 
or  when  a  consumptive  does  not  hold  some- 
thing before  his  mouth  when  he  coughs;  we 
need  have  no  fear  then  of  a  clean  consump- 
tive, one  who  properly  and  safely  disposes  of 
his  sputum. 

In  sanatoria  or  hospitals  for  the  tuberculous, 
it  is  a  rare  occurrence  for  the  physicians  or 
attendants  to  contract  the  disease,  because 
strict  precautions  are  observed  in  destroying 
the  sputum.  The  dust  has  been  examined 
in  such  institutions  and  no  tubercle  bacilli 
have  been  found  in  it  unless  some  patient  has 

41 


TUBERCULOSIS 

been  neglectful  of  the  rules  in  regard  to 
properly  disposing  of  the  sputum.  On  the 
other  hand.  Cornet,  a  German  physician,  and 
many  other  investigators  have  found  in  the 
dust  of  rooms  occupied  by  unclean  consump- 
tives, particularly  in  rooms  which  were  dark 
and  damp,  the  tubercle  bacilli,  even  days  or 
weeks  after  the  consumptive  had  died  or  been 
removed  from  the  room.  Cornet's  conclu- 
sions are  of  importance  in  discrediting  the 
popular  opinion  of  the  ubiquity  of  the  tubercle 
bacillus.  He  says :  "  The  tubercle  bacillus  is 
found,  as  a  rule,  only  in  places  in  which  an 
uncleanly  consumptive  maintains  himself; 
otherwise,  it  occurs  but  rarely." 

This  fact  is  of  vast  importance  also  in  our 
efforts  to  control  and  prevent  the  disease,  for 
it  shows  us  that  our  main  work  must  be  in 
the  home  of  the  consumptives.  When  viewed 
from  the  standpoint  of  prevention,  the  protec- 
tion of  the  family  of  the  consumptive  is  of 
far  greater  importance  to  the  community  than 
the  care  or  even  the  cure  of  the  consumptive 
himself.  If  the  consumptive  is  not  or  cannot 
be  made  to  safely  dispose  of  his  sputum,  he 
must  be  removed  to  a  hospital  and  his  chil- 
dren must  be  kept  constantly  under  observa- 

42 


A    CONTAGIOUS    DISEASE 

tion,  and  in  some  cases  removed  from  their 
homes. 

"  Consumption  Terror  " 

It  is  unfortunate  that  the  terms  contagious 
and  infectious  have  been  applied  to  tuberculo- 
sis, as  true  as  it  is ;  "  communicable  "  would 
have  been  a  better  term,  for  the  distinction 
in  the  conditions  of  infection  between  an 
acute  and  chronic  contagious  disease,  as  has 
been  pointed  out  above,  is  not  clearly  recog- 
nized in  the  popular  mind.  Because  tubercu- 
losis is  called  contagious,  it  is  often  classed 
in  the  same  catagory  as  the  acute  contagious 
diseases,  and  the  same  fear  has  been  aroused 
as  in  regard  to  the  latter  diseases.  This  fear 
has  led  to  a  great  injustice  being  done  the 
,poor  consumptive:  he  has  been  shunned  and 
treated  as  if  he  were  a  leper,  or  suffering 
from  an  acute  infection.  This  "  consumption 
terror,"  as  it  has  been  called,  has  not  only 
been  the  means  of  inflicting  great  hardships 
and  suffering  upon  the  consumptive  himself, 
but  has  seriously  interfered  with  the  general 
work  of  prevention. 

For  instance,  it  has  not  infrequently  hap- 
pened that  the  establishment  of  sanatoria  or 

43 


TUBERCULOSIS 

dispensaries  for  tuberculosis  has  been  op- 
posed or  rendered  impossible  by  those  living 
in  the  neighborhood  on  account  of  this  unrea- 
sonable fear,  whereas,  carefully  collected  sta- 
tistics have  shown  that  the  mortality  from 
tuberculosis  has  been  reduced  in  places  where 
sanatoria  have  been  established.  For  exam- 
ple, in  Goerbersdorf  and  Faulkenstein,  where 
several  sanatoria  have  existed  for  many  years, 
the  death  rate  from  consumption  has  mark- 
edly decreased.  This  has  been  brought  about 
by  the  example  set  by  the  sanatorium  of  a 
high  standard  of  sanitation  and  hygiene,  which 
was  imitated  by  those  living  in  the  neighbor- 
hood. Again,  it  is  often  difficult  for  a  con- 
sumptive and  his  family  to  obtain  a  dwelling 
or  a  tenement  on  account  of  the  "  consump- 
tion terror,"  or  a  consumptive  workman  may 
lose  his  position  through  the  "  consumption 
terror  "  on  the  part  of  his  fellow-workmen. 

An  incident  was  recently  related  of  a  con- 
sumptive tailor  who  expectorated  upon  the 
floor  of  the  shop,  about  him,  although  he 
knew  better,  for  fear  that  he  would  lose  his 
position  if  he  was  observed  to  use  a  proper 
receptacle  for  his  sputum.  In  many  hotels, 
particularly    in    health   resorts,    consumptives 

44 


A    CONTAGIOUS    DISEASE 

are  not  received  under  any  condition,  and 
are  often  almost  cruelly  turned  away.  This 
is  not  so  much  the  fault  of  the  proprietors 
as  the  unreasoning  fear  of  the  guests.  Even 
consumptives  who  have  been  discharged 
from  the  sanatorium  with  their  disease  cured, 
often  find  it  difficult  to  obtain  a  position  if 
the  fact  is  known.  The  unfortunate  con- 
sumptive often  suffers  more  from  this  heart- 
less, ignorant,  cowardly  fear  than  he  does  from 
the  disease  itself. 

The  Only  Way  Consumption  is  Conveyed 

It  is  therefore  of  the  highest  importance 
that  everyone  should  remember  that  it  is  only 
the  expectorated  sputum  of  the  consumptive, 
and  that  alone,  which  contains  the  infecting 
material,  the  tubercle  bacilli,  and  which  can 
carry  the  disease  from  one  person  to  another, 
and  that  when  this  sputum  is  destroyed  before 
it  becomes  dry,  the  consumptive  is  harmless. 
Furthermore,  no  one  need  fear  that  he  will 
become  infected  by  coming  in  contact  with  a 
consumptive  for  a  short  time;  or  staying  with 
a  consumptive  who  does  not  cough,  or  who 
properly  disposes  of  his  sputum.  It  may  well 
be  repeated  again  that  to  be  infected  by  tuber- 

45 


TUBERCULOSIS 

culosis,  one  must  for  a  considerable  time  live 
or  work  continuously  with  a  consumptive  who 
coughs  and  who  is  not  careful  in  the  dispo- 
sition of  his  sputum.  The  Swedish  National 
Anti-Tuberculosis  Association  has  thus  admi- 
rably summarized  the  evils  of  the  "  consump- 
tion terror  " : 

The  "  consumption  terror "  paralyzes  the 
struggle  against  tuberculosis. 

The  "  consumption  terror "  prevents  con- 
sumptives from  taking  care  of  themselves. 

The  "  consumption  terror "  renders  all 
measures  against  tuberculosis  more  difficult. 

The  "  consumption  terror "  facilitates  the 
spread  of  infection. 

The  *'  consumption  terror "  causes  us  to 
overlook  the  real  danger. 

The  "  consumption  terror "  is  a  sign  of 
shameful  cowardice. 

The  "  consumption  terror  "  causes  cruel  be- 
havior to  consumptives. 

The  "  consumption  terror  "  is  an  enemy  to 
society  that  must  be  opposed. 


4B 


IV.    INHERITANCE  AND    IMMUNITY 

OR.  HOLMES  somewhere  wittily 
says  that  in  order  to  produce  a 
high  type  of  human  being,  "  a 
man  should  be  careful  in  the 
selection  of  his  ancestors."  The 
work  must  have  its  beginning  with  the  grand- 
parents or  great-grandparents.  In  other 
words,  he  evidently  meant  to  say  that  inherit- 
ance played  a  very  important;  part  in  the 
moral,  physical,  and  intellectual  welfare  of 
a  man.  Inheritance  does,  undoubtedly,  exer- 
cise a  very  material  influence  in  shaping  one's 
career  and  character,  as  the  new  science  of  eu- 
genics teaches,  how  much,  no  one  knows ;  but 
we  often  ascribe  to  it  many  defects  in  the 
moral  and  physical  condition  of  a  person,  for 
which  it  is  in  no  way  responsible  and  which 
are  within  his  own  control.  So  it  has  hap- 
pened with  regard  to  diseases,  the  cause  and 
origin  of  which  we  were  ignorant.  Either 
"  providence "  or  inheritance  were  often 
made  the  scapegoat  for  many  diseases  which 

47 


TUBERCULOSIS 

afflicted  mankind,  the  real  cause  of  which  was 
their  own  ignorance  or  disregard  of  nature's 
laws.  It  was  so  with  regard  to  tuberculosis. 
The  universal  belief  was,  that  it  was  an  in- 
herited disease,  and  even  now,  with  the  knowl- 
edge of  its  cause,  one  frequently  hears  the  old 
inheritance  doctrine  asserted,  such  is  the  te- 
nacity of  old  and  long-entertained  ideas. 

The  Old  Idea  Versus  the  New 

It  was  very  natural,  however,  that  in  the 
dark  days  of  tuberculosis,  as  we  might  call  the 
time  before  the  discovery  of  the  true  cause, 
one  should  thus  explain  the  frequent  occur- 
rence of  several  cases  of  the  disease  in  the 
same  family,  when  one  member  after  another 
succumbed  to  it.  "  How  else  can  this  be 
explained,"  one  said,  "except  by  inherit- 
ance ?  " 

With  the  discovery  of  the  fact  that  tuber- 
culosis was  an  infectious  or  communicable 
disease  caused  by  a  germ,  all  was  made  clear 
and  the  inheritance  theory  became  untenable. 
Not  knowing  that  the  fatal  germ,  the  tubercle 
bacillus,  lurked  in  the  sputum  of  a  consump- 
tive, no  care  was  taken  to  destroy  it  before 
it  became  dry,  and  so  the  disease  was  com- 

48 


INHERITANCE   AND    IMMUNITY 

municated  to  others  who  were  in  constant  at- 
tention upon,  or  in  intimate,  long-continued 
relation  with,  the  consumptive. 

What  was  ignorantly  regarded  as  inherit- 
ance was  simply  infection.  The  disease  was 
caught  through  the  germs,  not  inherited,  and 
so,  alas !  it  went  on  being  communicated,  until 
Koch's  discovery  removed  the  veil  of  igno- 
rance and  enlightened  the  world  as  to  the  true 
nature  of  the  disease,  and  the  danger  from 
the  dried  sputum. 

What  is  "Inheritance"? 

Still,  however,  we  retain  the  word  inherit- 
ance, with  regard  to  tuberculosis,  but  with  a 
different  meaning.  We  say  now,  that  a  ten- 
dency to  it,  or  a  predisposition  to  it,  is  inher- 
ited, that  when  a  person  has  tuberculosis  "  in 
the  family,"  when,  for  example,  his  father 
or  mother  has  died  of  it,  he  may  have  inher- 
ited in  consequence  a  tendency  to  the  disease 
and  is  more  likely  to  contract  it  when  exposed 
to  the  bacilli. 

The  occurrence  of  tuberculosis  in  the  fam- 
ily of  one  suffering  from  the  disease,  either 
on  the  father's  or  mother's  side  or  on  both,  is 
so  frequent  that  the  inheritance  of  a  predispo- 

49 


TUBERCULOSIS 

sition  to  the  disease  would  seem  to  be  evident. 
It  must  be  remembered,  however,  that  the  op- 
portunities for  contracting  the  disease  in  a 
household  where  some  member  is  suffering 
from  it  are  naturally  greater  than  when  no 
such  case  exists,  for,  unfortunately,  there  are 
still  many  homes  where  the  dangers  from  the 
dried  sputum  are  still  not  fully  realized.  What, 
therefore,  we  ascribe  to  inheritance,  is,  un- 
doubtedly, in  many  cases  only  the  result  of 
greater  opportunities  for  infection. 

It  may  be  that  a  special  susceptibility  to 
tuberculosis  is  really  inherited,  but,  on  the 
other  hand,  the  true  fact  may  be  only  this, 
that  the  children  of  consumptive  parents,  espe- 
cially of  a  consumptive  mother,  are  not  as 
robust  and  resistant  as  those  whose  parents 
were  well  and  strong  when  they  were  born, 
and  hence,  they  are  more  susceptible  to  any 
infectious  disease,  including  tuberculosis,  and, 
furthermore,  if  the  tuberculous  parent  is  liv- 
ing with  the  children  in  the  same  household, 
the  opportunities  for  infection  are  greater,  as 
has  been  said. 

The  practical  lesson  from  all  this  is,  that 
weakly  children  should  receive  especial  atten- 
tion and  very  effort  made  to  build  up  their 

50 


INHERITANCE   AND    IMMUNITY 

strength  and  health  and  increase  their  resist- 
ing" power  to  disease,  and,  secondly,  they 
should  be  removed  from  sources  of  infection. 
A  consumptive  mother  should  not  nurse  her 
baby,  or  children  should  not  be  permitted  to 
live  in  intimate  association  with  consumptive 
parents  or  relatives.  Moreover,  all  the  chil- 
dren from  a  household  where  a  case  of  tuber- 
culosis exists,  should  receive  a  careful  exam- 
ination from  time  to  time.  Where  this  has 
been  done,  as  is  now  the  custom  in  tubercu- 
losis dispensaries,  unsuspected  cases  have  been 
discovered,  and  when  the  disease  is  detected 
and  treated  in  its  beginning,  as  will  later  be 
shown,  the  cure  will  generally  follow. 

Predisposition  and  Immunity 

We  now  also  use  the  word  "  predisposition  '* 
in  still  another  sense.  We  speak  of  an  "  ac- 
quired predisposition,"  which  means  that  an 
individual  may  by  various  unwholesome  influ- 
ences of  living  and  unfavorable  environment 
(which  will  be  considered  more  at  length  in 
the  next  chapter),  so  reduce  his  resistance  to 
disease  that  his  system  readily  yields  to  infec- 
tious germs  of  any  kind  when  exposed  to  them, 
and  among  them,  to  the  germs  of  tuberculo- 

51 


TUBERCULOSIS 

sis.  Such  an  individual,  we  say,  has,  by  his 
faulty  method  of  living,  acquired  a  "  predis- 
position "  to  the  disease.  He  has  lowered  his 
resistance  either  permanently  or  temporarily. 
Upon  this  fact  of  lowered  resistance  is  based 
the  modern  method  of  treatment  of  tubercu- 
losis, which  consists,  in  brief,  in  placing  the 
patient  under  such  favorable  conditions  of 
living  that  his  system  will  regain  this  lost  re- 
sistance to  disease  and  re-establish  what  we 
call  his  natural  "  immunity." 

Every  individual  possesses  within  his  body 
to  a  greater  or  less  degree  a  natural  tendency 
to  resist  disease.  This  inborn  tendency  we 
call  one's  natural  "  immunity."  When  any 
poisonous  or  infectious  germ  enters  the  body, 
a  defensive  army  is  set  in  operation  within 
the  body  which  endeavors  to  destroy  or  limit 
the  influence  of  such  germs,  and  the  activity 
of  this  opposing  army  depends  upon  the  degree 
of  immunity  the  individual  possesses. 

The  white  blood  cells  called  "  leucocytes  " 
possess  the  power  to  a  greater  or  less  extent 
of  destroying  infectious  germs.  This  they 
do  by  enveloping  or  eating  them  up,  so  to 
speak.  This  process  is  called  "  phagocytosis  " 
and    was    first    demonstrated    by    a    famous 

52 


INHERITANCE   AND    IMMUNITY 

French  investigator,  Metchinkoff,  who  is  the 
successor  to  the  more  famous  Pasteur, 

It  is  a  very  wonderful  provision  of  nature 
that  when  any  infectious  material  enters  the 
body,  the  number  of  leucocytes  or  white  blood 
cells  are  generally  increased.  Nature  calls 
out  her  reserves  as  the  danger  arises  or  in- 
creases. When,  in  any  infectious  disease,  we 
find  a  large  increase  in  these  scavenger  cells, 
the  leucocytes,  we  say  the  fight  is  going  on 
well,  but,  when,  on  the  contrary,  there  is  no 
increase,  we  are  fearful  of  the  result.  Pneu- 
monia is  a  good  illustration  of  this  process. 
When  by  microscopical  count  the  blood  shows 
few  leucocytes,  we  give  a  grave  prognosis. 
Further  investigation  has  shown  that  other 
cells  and  fluids  of  the  body  also  assist  in  this 
work  of  destroying  or  rendering  inactive  in- 
fectious germs,  and  there  still  remains  much 
to  be  learned  about  all  the  causes  of  natural 
immunity. 

Antitoxins  and  Vaccines 

As  is  well  known,  we  can  also  inject  into 
the  body  various  antitoxins  or  vaccines  which 
will  further  increase  the  defensive  barriers 
of  the  body  and  neutralize  or  destroy  the 

53 


TUBERCULOSIS 

toxins  or  poisons  produced  by  the  various 
specific  bacteria  or  germs,  will  produce  an 
artificial  immunity.  This  we  do  with  success 
in  diphtheria  by  use  of  the  well-known  diph- 
theria antitoxin,  and  in  tetanus,  or  "  lock- 
jaw," with  more  or  less  success  by  the  tetanus 
antitoxin,  and  in  cerebro-spinal  meningitis  by 
its  peculiar  antitoxin. 

The  great  goal  toward  which  the  modern 
medical  world  is  now  striving  is  to  discover 
antitoxins  or  vaccines  for  all  infectious 
diseases,  so  that,  for  example,  when  pneu- 
monia, scarlet  fever,  and  other  diseases,  caused 
by  specific  bacteria  or  germs,  occur,  we  may 
vaccinate  or  inject  into  the  body  the  proper 
antitoxin  or  vaccine  for  each  disease  and  thus 
cut  short  its  course,  just  as  we  now  success- 
fully do  in  diphtheria.  Many  attempts  have 
been  made  to  discover  an  efficient  antitoxin 
or  vaccine  for  tuberculosis,  but  as  yet  it  has 
not  been  found.  Maragliano,  a  celebrated 
Italian  physician,  thought  he  had  discovered 
such  an  antitoxin  or  serum,  and  so  did  Von 
Behring,  the  man  who  discovered  the  diph- 
theria antitoxin.  Dr.  Trudeau  also,  the  great- 
est investigator  in  this  country  upon  tuber- 
culosis problems,  has,  for  many  years,  been 

54 


INHERITANCE   AND   IMMUNITY 

working  in  this  direction  and  so  have  many 
others.  None  of  these  men,  however,  has  as 
yet  produced  an  antitoxin  which  can  in  any 
degree  do  for  tuberculosis  in  the  human  being 
what  the  antitoxin  does  in  diphtheria.  Still, 
however,  these  illustrious  investigators  pa- 
tiently work  on  with  a  host  of  others,  and  we 
may  hope  that  eventually  success  will  come  and 
the  true  tuberculosis  antitoxin  be  discovered. 
"  Tuberculin,"  a  sort  of  serum  or  anti- 
toxin made  from  the  tubercle  bacilli,  origi- 
nally prepared  by  Koch,  was  at  first  thought 
to  be  a  genuine  antitoxin  for  tuberculosis,  and 
when  Dr.  Koch  first  gave  it  to  the  medical 
public,  consumptives  flocked  to  Berlin  to  be 
treated  with  the  marvelous  specific,  as  it  was 
then  supposed  to  be,  and  physicians  from  all 
over  the  world  were  besieging  Dr.  Koch  for 
some  of  the  precious  substance  for  their  con- 
sumptive patients.  Hope  was  high  that  at 
last  the  great  physician  who  had  discovered 
the  cause  had  also  discovered  the  remedy. 
Alas !  both  physician  and  patient  were  doomed 
to  cruel  disappointment.  The  tuberculin  did 
more  harm  than  good,  for  many  lives  were 
sacrificed  in  an  overzealous  use  of  it  in  almost 
poisonous  doses.     The  awakening  soon  came 

55 


TUBERCULOSIS 

and  the  supposed  specific,  tuberculin,  was 
abandoned  as  suddenly  as  it  had  leaped  into 
favor.  Subsequent  experience,  however,  has 
apparently  shown,  that,  employed  in  infinitely 
small  doses  and  with  proper  cases,  it  has  more 
or  less  value  when  used  in  connection  with 
the  open-air  treatment.  Its  eflfect  seems  to 
be  to  increase  the  resisting  power  of  the  indi- 
vidual. 

Tuberculin,  when  used  with  animals,  seems 
to  give  immunity  to  the  tubercle  bacillus. 
Koch,  Dr.  Trudeau,  Von  Behring,  and  others 
have  obtained  such  a  result  in  their  experi- 
ments with  animals.  But  it  has  often  been 
found  that  what  has  succeeded  in  animal  ex- 
perimentation has  failed  in  human  beings, 
although  it  must  not  be  forgotten  that,  on 
the  other  hand,  animal  experimentation  has 
led  to  many  discoveries  which  have  conferred 
lasting  and  great  benefits  upon  mankind. 

Immunity  in  Acute  Diseases 

It  has  been  thought  and  there  are  some  facts 
which  appear  to  corroborate  the  belief  that 
sometimes  one  receives  from  parents  who  have 
died  of  tuberculosis  an  immunity  to  the 
disease.     If  this  is  really  so,  it  unfortunately 

56 


INHERITANCE   AND    IMMUNITY 

happens  but  rarely.     With  the  acute  infectious 
diseases,  however,  like  whooping  cough,  mea- 
sles, etc.,  a  single  attack  generally  produces 
an  immunity  to  subsequent  attacks  of  the  same 
disease.     But  this,  as  we  know,  is  not  the  case 
with   the   chronic   infectious    diseases.     How 
fortunate  it   would  be  if,   having   recovered 
from  tuberculosis,  one  was  assured,  in  conse- 
quence, that  he  would  never  suffer  from  it 
again  and  there  is  some  evidence  to  show  that 
a  tuberculous  focus  somewhere  in  the  body  or 
a  slight  tuberculous  infection  does  produce  a 
partial  immunity.     At  the  present  time,  then, 
we  can  only  strive  to  increase  the  natural  re- 
sisting power,  the  "  natural  immunity  "  of  the 
individual,  and  hope  that  future  investigations 
and  research  may  bring  us  the  much-desired 
antitoxin  or  vaccine  for  tuberculosis. 


57 


V.    THE   SEED   AND   SOIL 

^J^^^^  WO  things  are  necessary  in  order 
m  C^\  to  contract  a  contagious  disease, 
K  I    whether    it    be    an    acute    or    a 

^^^^^^  chronic  one:  the  one  is  the  pres- 
ence of  the  infection — the  germs 
of  the  special  disease — and  its  entrance  into 
the  body  in  a  sufficient  quantity ;  and  the  other 
is  a  receptive  state  in  the  individual.  Not 
everyone  who  is  exposed  to  an  acute  infec- 
tious disease  contracts  it,  as  we  know,  and, 
likewise,  not  everyone  who  is  exposed  to  the 
infection  of  tuberculosis — the  tubercle  bacilli 
— becomes  a  victim  to  it.  Neither,  on  the 
contrary,  can  anyone,  however  receptive  his 
condition  may  be,  contract  tuberculosis,  or, 
indeed,  any  contagious  disease,  unless  he  is 
exposed  to  the  germs  of  that  disease.  No 
matter  how  susceptible  the  individual  or  how 
little  his  resistance,  how  unfavorable  his  en- 
vironment or  how  unhygienic  the  conditions 
may  be,  if  the  specific  micro-organism  is  ab- 
sent tuberculosis  is  impossible. 

58 


SEED   AND   SOIL 

Two  Things  Necessary  to  Contagion 

Some  years  ago  there  was  no  tuberculosis 
in  Iceland,  and  yet  the  inhabitants  of  this 
island  lived  under  the  most  unfavorable  and 
unhygienic  conditions.  The  winter  was  long 
and  dreary,  and  the  sky  cloudy  and  the  atmos- 
phere filled  with  dampness.  Their  dwellings 
were  small,  dirty,  dark,  and  unventilated,  each 
person  having  scarcely  ninety-nine  cubic  feet 
of  air  to  breathe.  These  abodes  were  filled 
with  foul-smelling  vapor  rising  from  the  de- 
bris of  fish  lying  about  the  door,  and  the  smoke 
from  dried  dung  which  constituted  their  fuel. 
Their  food  consisted  mainly  of  dried  fish  which 
had  begun  to  putrify,  a  preparation  of  milk 
called  "  sky,"  large  quantities  of  rancid  but- 
ter, and  sour  whey  mixed  with  water;  they 
also  drank  large  quantities  of  alcohol.  Their 
occupation  was  one  of  exposure  in  fishing, 
bird  hunting,  and  sheep  and  cattle  herding. 
Their  feet  were  constantly  wet.  In  spite  of 
this  extraordinarily  unwholesome  and  perni- 
cious condition  of  existence,  no  case  of  pul- 
monary tuberculosis  existed.  The  suscepti- 
ble condition  was  undoubtedly  present,  but  the 
tubercle  bacillus  was  absent.  Whenever  any 
of  the  Icelanders  migrated  to  the  mainland 

59 


TUBERCULOSIS 

of  Denmark  tuberculosis  was  extraordinarily 
frequent  among  them,  as  one  would  expect, 
for  then  occurred  the  union  of  the  favorable 
soil,  the  susceptible  condition,  produced  by  the 
unhygienic  life  of  the  Icelander,  with  the 
tubercle  bacillus  existing  in  Denmark. 

We  must  have,  then,  both  good  seed  and  a 
favorable  soil,  a  soil  suited  to  the  growth  of 
the  seed,  in  order  that  a  crop  may  be  produced 
and  come  to  maturity.  The  seed  must  fall 
upon  "good  soil,"  as  in  the  parable  of  the 
seed  and  the  sower. 

The  Favorable  Soil 

What  the  seed  is  in  tuberculosis  we  have 
already  learned:  it  is  the  tubercle  bacillus. 
How  it  is  obtained,  we  also  know:  it  comes 
from  the  sputum  of  an  individual  suffering 
from  the  disease.  We  have  now  to  consider 
the  favorable  soil  and  how  it  is  produced,  or, 
in  other  words,  what  influences  or  conditions 
render  one  receptive  to  the  tubercle  bacillus. 
Although  we  cannot  say  in  any  individual 
case  what  especial  unfavorable  condition  may 
render  him  receptive,  for  we  have  no  means 
of  measuring  the  subtile  something  which  we 
call  one's  resistance  to  disease,  still  observa- 

60 


SEED   AND   SOIL 

tion  and  experience  have  taught  us  in  a  gen- 
eral way  under  what  conditions  this  receptive 
state  to  tuberculosis  is  most  likely  to  occur. 
In  studying  many  cases  of  tuberculosis,  cer- 
tain influences  in  the  previous  or  present  life 
of  the  consumptive,  or  in  his  surroundings, 
have  been  so  frequently  found  to  be  present, 
that  we  can  infer  with  a  great  probability  of 
truth  that  these  influences  must  have  been 
important  factors  in  preparing  the  favorable 
soil  and  in  rendering  the  individual  suscepti- 
ble to  the  infecting  germ,  the  tubercle  ba- 
cillus. 

In  general,  we  have  found  that  anything 
which  impairs  the  general  health  of  a  person 
may  be  a  predisposing  cause  to  tuberculosis. 
In  the  first  place,  certain  diseases  from  which 
the  patient  has  previously  suffered  appear  to 
be  predisposing  causes.  Such  are  whooping 
cough,  bronchitis,  influenza,  popularly  known 
as  the  "  grippe,"  measles,  and,  to  a  less  extent, 
scarlet  fever,  typhoid  fever,  pleurisy,  diabetes, 
syphilis  and,  perhaps,  others.  It  must  be  said, 
however,  in  this  connection,  that  probably  in 
some  cases  where  these  diseases  have  occurred,, 
the  tuberculosis  was  already  present  in  a  latent 
condition,  and  the  disease  rendered  it  active. 

6i 


TUBERCULOSIS 

This  seems  to  be  especially  the  case  with  influ^ 
enza.  The  practical  lesson  to  be  drawn  from 
this  is  that  especial  attention  should  be  given 
to  those  convalescing  from  the  acute  diseases 
mentioned  above,  so  that  a  thorough  recovery 
may  ensue  and  one's  normal  resisting  power 
be  established  as  soon  as  possible,  and  that  one 
should  avoid  close  association  with  those  suf- 
fering from  influenza  or  a  "  cold." 

In  children  enlarged  tonsils  and  the  growth 
in  the  back  of  the  nose  called  "  adenoids  '* 
afford  a  favorable  local  soil  for  the  tubercle 
bacilli,  and  they  have  been  found  in  these 
places.  Moreover,  the  "  adenoids "  by  ob- 
structing the  nose,  and  the  tonsils  by  narrow- 
ing the  passage  into  the  lungs  render  respira- 
tion inadequate,  and  in  consequence  the  chest 
fails  of  its  full  development.  The  whole  body 
suffers  from  the  defective  aeration  and  be- 
comes less  resistant  to  the  tuberculosis  infec- 
tion. This  subject  will  be  again  referred  to 
when  speaking  of  tuberculosis  and  the  child. 

The  " Neglected  Cold" 

The  so-called  "  neglected  cold "  is  often 
adduced  as  a  frequent  exciting  cause  of  pul- 
monary tuberculosis,  and  when  one  considers 
the  enormous  frequency  of  colds  in  northern 

62 


SEED   AND    SOIL 

climates  during  the  winter  season,  such  would 
seem  to  be  the  fact.  In  2700  supposedly  well 
men  examined  by  the  writer  41.4  per  cent, 
complained  of  colds  in  the  head  or  throat. 
It  is  undoubtedly  true  that  what  is  often  called 
a  "  cold  "  is  the  real  beginning  of  tuberculosis : 
one  begins  to  cough  from  the  irritation  caused 
by  tuberculosis,  and  therefore  he  thinks,  quite 
naturally,  that  "  it  is  a  cold."  Nevertheless,  a 
simple  cold  neglected  may  open  the  door  for 
the  tubercle  bacillus  to  enter.  Modern  bacte- 
riological studies  have  taught  us  that  all  colds 
or  catarrhs  are  caused  by  infection  by  some 
germ  or  combination  of  germs ;  but  "  cold  " 
germs,  like  tuberculosis  germs,  must  have  a 
suitable  soil,  an  exciting  cause.  What  are 
some  of  these  causes?  Impure  air,  dust,  ex- 
treme and  sudden  alterations  of  temperature, 
excessive  indoor  temperature,  dry  heat,  lack 
of  physical  exercise,  and  inadequate  respira- 
tion, neglect  of  daily  cold  bathing  of  the 
throat  and  chest,  an  excessive  amount  of 
clothing,  insufficient  sleep  and  rest,  mouth 
breathing,  excess  in  eating  and  drinking,  con- 
stipation. These  neglected  colds  or  fre- 
quently recurring  catarrhal  affections  "may 
form  predisposing  causes,"  says  Dr.  Webber, 
"  either  by  producing  sore  places  in  the  lining 

63 


TUBERCULOSIS 

membrane  of  the  respiratory  tract,  called  the 
mucous  membrane,  and  thus  allowing  the 
bacilli  to  settle,  or  by  weakening  the  cells  of 
this  mucous  membrane  and  their  ciliary  (pro- 
tective) action," — for  these  cilicB  are  tiny,  hair- 
like bodies,  constantly  in  motion,  and  like  a 
street  sweeper,  constantly  sweeping  out  all 
impurities  from  the  respiratory  passages, — 
"  or  by  causing  imperfect  breathing  from  un- 
consciously avoiding  deep  inspiration  in  order 
to  avoid  coughing,  or  by  weakening  the  nutri- 
tion and  energy  of  the  whole  system.'* 

Overcrowding  as  a  Cause  of  Tuberculosis 

All  the  innumerable  evils  of  unsanitary  liv- 
ing, which  depress  one's  vitality,  are  obviously 
potent  influences  in  preparing  the  favorable 
soil  for  the  tubercle  bacillus.  Overcrowding, 
as  in  the  tenements  of  the  poor  in  large  cities, 
is  everywhere  recognized  as  one  of  the  great 
predisposing  causes.  Thus,  in  Paris,  where 
so  much  pulmonary  tuberculosis  exists  and 
where  more  than  three-fourths  of  all  the  fami- 
lies live  in  three  rooms  or  less,  it  has  been 
found  that  the  number  of  cases  of  tuberculosis 
increases  as  the  number  of  rooms  in  a  tene- 
ment decreases.     In  London,  statistics  show 

64 


SEED   AND   SOIL 

that  the  death  rate  from  tuberculosis  varies 
according  to  the  number  of  persons  in  a  room. 
In  the  famous  so-called  *'  lung  block  "  in  New 
York  City,  a  great  block  of  the  worst  kind  of 
tenements,  densely  inhabited,  very  many  cases 
of  tuberculosis  were  found  to  exist.  In  asy- 
lums, prisons,  and  other  institutions  where 
large  numbers  of  human  beings  are  kept 
in  close  contact,  pulmonary  tuberculosis 
was  frequently  the  most  common  disease 
among  the  inmates,  and  sometimes  produced 
an  almost  epidemic  mortality.  In  recent  years 
especial  provision  has  been  made  in  many 
asylums  and  prisons  for  removing  the  con- 
sumptive inmates  and  placing  them  under 
open-air  conditions  of  living  in  much  the 
same  way  as  in  a  sanatorium.  Of  course, 
overcrowding  acts  in  two  ways;  greater  op- 
portunities of  contracting  the  disease  are  af- 
forded, for  there  are  quite  sure  to  be  some 
consumptives  present,  and  at  the  same  time 
the  health  of  all  is  impaired  by  the  unwhole- 
some conditions  incident  to  the  overcrowd- 
ing. 

Whenever,  in  the  remote  past,  tuberculosis 
first  originated,  it  was  probably  coincident 
with  the  concentration  of  human  beings  in 

65 


TUBERCULOSIS 

small  areas,  crowding*  together,  and  with  the 
building-  of  closed  places  of  abode,  for,  as  we 
have  seen,  it  is,  for  the  most  part,  a  disease 
of  indoor  life,  a  "  house  disease."  In  the; 
evolution  of  civilization,  we  have  reversed 
the  natural  order  of  things,  and  instead  of 
regarding  indoor  life  the  exception,  we  have 
made  it  the  rule;  and  in  northern  latitudes 
we  spend  the  greater  part  of  the  twenty-four 
hours  under  artificial  conditions,  where  we 
breathe  air  as  devoid  of  moisture  as  the  Desert 
of  Sahara,  and  heated  to  a  temperature  of  70° 
or  more.  Such  hot,  dry  air  impairs  the  pro- 
tective apparatus  of  the  upper  respiratory 
tract,  and  bacteria  can  gain  a  more  ready  en- 
trance. We  have  become  so  accustomed  to 
this  abnormal,  constant  indoor  life,  that  its 
dangers  are  lost  sight  of,  but  they  are  none 
the  less  real,  and  especially  menace  those  of 
deficient  vitality,  and  gradually  lower  one's 
resisting  power  to  disease. 

Fresh  Air  and  Sunshine 

Absence  of  fresh  air  and  sunshine  is  an- 
other powerful  predisposing  cause;  and  this 
is  a  condition  not  always  confined  to  the  tene- 
ment houses  of  the  poor,  but  also  not  infre- 

66 


SEED    AND   SOIL 

quently  existent  in  the  apartments  of  the  well- 
to-do.  In  the  tenements  of  New  York  City 
there  were  found  to  be  350,000  dark  interior 
rooms  with  no  windows  admitting  fresh  air 
and  sunshine.  Fresh  air  is  as  necessary  as 
food.  Indeed,  it  is  food  for  the  blood,  which 
is  the  elaborated  food  of  the  body.  Fresh 
air  stimulates  and  maintains  in  a  vigorous 
state  the  lung  tissue  itself.  If  impure,  dirty 
air  was  as  visible  as  dirty  water,  we  should 
be  less  ready  to  bathe  our  lungs  in  it,  in  our 
houses  and  in  public  places  and  in  vehicles ; 
and  we  should  to  a  far  greater  degree  recog- 
nize its  dangers. 

Sunshine  is  equally  necessary  for  a  health- 
ful existence,  and  without  it  one  becomes 
sickly  and  pale  like  a  plant  in  a  cellar.  An 
instance  is  related  of  a  family,  consisting  of 
a  man,  his  wife  and  five  children,  previously 
perfectly  healthy,  who  moved  to  Paris  from 
the  country  and  lived  in  a  cellar.  The  chil- 
dren and  mother  died  quickly  of  tuberculosis, 
which  first  attacked  the  children:  the  father, 
who  worked  in  the  open  air,  alone  escaped. 
"  Where  sunlight  enters  not,  there  the  physi- 
cian goes,"  says  the  old  proverb.  Sunshine 
will  destroy  the  tubercle  bacilli  in  a  short  time. 


TUBERCULOSIS 

Sunshine  brings  cheerfulness  of  spirits  and 
invigorates  the  body,  and  its  beneficent  influ- 
ence is  probably  far  greater  than  we  can  as 
yet  estimate.  At  Rollier's  sanatorium  in  Ley- 
sin,  Switzerland,  children  with  bone,  joint  and 
gland  tuberculosis  are  exposed  naked  for  hours 
to  the  direct  rays  of  the  sun,  and  with  re- 
markably beneficial  results. 

Dr.  Trudeau's  famous  experiment  with  the 
rabbits  well  illustrates  the  evil  effects  of  the 
absence  of  fresh  air  and  sunshine.  He  inocu- 
lated a  number  of  rabbits  with  equal  doses  of 
tubercle  bacilli,  and  then  he  allowed  half  of 
them  to  run  free  in  the  fresh  air  and  sun- 
light, while  the  other  half  were  confined  in  a 
dark  cellar  where  the  sunlight  and  fresh  air 
were  excluded.  Both  sets  of  rabbits  were 
killed  at  the  same  time ;  those  which  had  been 
allowed  to  run  free  had  recovered  or  showed 
only  slight  disease,  while  those  which  were 
confined  in  the  dark  place  had  extensive  tuber- 
culosis. 

A  member  of  Nansen's  Arctic  expedition 
thus  describes  the  alternate  influence  of  dark- 
ness and  sunlight  upon  the  mind  and  body. 
He  says :  "  The  last  winter  in  the  ice  was 
simply  awful.  We  had  our  fill  of  the  dark- 
ness. We  got  sleepy  and  indifferent,  and 
shaky  on  our  legs.     We  were  not  ill,  but  weak 

6S 


SEED    AND    SOIL 

and  dead  beat,  and  the  doctor  was  anxious 
about  our  brains.  When  the  day  came,  with 
the  sun,  it  was  like  a  resurrection  for  us  all. 
We  were  electrified  when  we  saw  him.  No- 
body knows  how  fine  the  sun  looks  but  those 
who  have  been  six  months  in  darkness.  Then 
we  came  to  strength  aofain." 

So  long  as  modern  civilization  and  indus- 
trialism require  such  constant  and  almost  com- 
plete indoor  existence,  great  care  should  be 
taken  that  the  fresh  air  and  sunshine  have 
abundant  access  to  the  house,  factory,  work- 
shop, and  store.  How  many  a  poor  clerk,  book- 
keeper, or  shop  girl  in  a  department  store  has 
been  and  is  preparing  a  favorable  soil  for  the 
tubercle  bacillus,  by  being  confined  in  some 
dark  corner  in  the  basement  or  elsewhere 
where  the  sun  never  enters  and  the  contami- 
nated, foul  air  is  never  changed  by  proper 
ventilation!  Even  the  well-to-do,  who  can 
command  the  situation,  too  often  forgets  the 
invigorating  influences  of  fresh  air  and  sun- 
shine. "  He  deliberately  turns  his  back  upon 
the  light  of  the  sun,"  says  Mr.  Edward  Car- 
penter in  his  "  Civilization — its  Cause  and 
Cure,"  "  and  hides  himself  away  in  boxes 
with  breathing  holes  (which  he  calls  houses), 
living  ever  more  and  more  in  darkness  and 
asphyxia,  and  only  coming  forth  perhaps  once 

69 


TUBERCULOSIS 

a  day  to  blink  at  the  bright  g*od,  or  to  run 
back  again  at  the  first  breath  of  the  free  wind 
for  fear  of  catching  cold ! " 

Evils   of   Inadequate   Respiration 

Inadequate  and  partial  respiration  is,  in  the 
writer's  opinion  and  experience,  a  frequent 
predisposing  cause  of  tuberculosis,  and,  in  our 
sedentary  life,  is  a  very  common  condition. 
Not  only  is  the  resisting  power  of  the  lung 
tissue  itself  diminished,  but  the  aeration  of 
the  blood,  upon  which  depend  so  largely  all 
the  vital  processes,  is  imperfectly  performed. 
Full  and  free  breathing  strengthens  the  pul- 
monary tissue,  increases  its  vitality  and  con- 
sequently its  power  of  resistance  to  disease. 
In  his  original  state  good  breathing  came 
naturally  to  man,  for  he  was  intended  to  be 
an  active  animal — to  run  and  climb,  to  bend 
and  twist  his  body,  to  stretch  and  extend  his 
arms,  and,  in  brief,  use  all  his  muscles,  and 
as  long  as  he  followed  Nature  in  this  respect, 
his  lungs  had  full  play  and  the  respiratory 
muscles  were  maintained  in  a  state  of  effi- 
ciency. So-called  civilization,  or,  at  least,  city 
civilization,  has  so  modified  all  this,  that  one's 
life,  in  a  large  number  of  occupations,  has 

70 


SEED  AND  SOIL 

resolved  itself  into  a  mental  hunt  for  sub- 
sistance  rather  than  an  active  bodily  one.  The 
natural  life,  with  its  bodily  activity,  has  be- 
come an  artificial  one  of  more  or  less  bodily 
immobility,  and  what  Nature  unconsciously 
did  to  promote  and  maintain  proper  breathing 
must  now  be  done  by  conscious  effort  and  arti- 
ficial methods,  such  as  gymnastics  and  ath- 
letic exercises  and  training. 

True,  a  person  might  perhaps  live  in  com- 
fortable health  in  this  inactive  condition,  only 
half-filling  and  using  his  lungs,  if  he  were  al- 
ways sure  of  remaining  in  it,  but  he  never 
knows  when  an  emergency  may  arise  which  will 
require  the  respiration  which  well-trained  lungs 
can  only  give,  be  it  running  for  the  doctor 
in  a  case  of  life  or  death,  swimming  to  save 
himself  in  a  shipwreck,  or  exposure  to  the 
tubercle  bacillus  when,  in  addition,  the  nutri- 
tion happens  to  be  poor  or  the  system  de- 
pressed. And,  further,  the  sense  of  physical 
well-being  is  much  greater  when  the  respira- 
tory tide  is  full  and  strong,  as  the  experience 
of  all  of  us  can  testify  after  some  exercise 
which  makes  large  demands  upon  the  "  wind," 
such  as  running,  a  game  of  tennis,  or  swim- 
ming.   As    some    one    has    well    said,    "  To 

71 


TUBERCULOSIS 

breathe  well  means  to  live  well,  to  live  longer 
and  to  live  better." 

Value  of  Proper  Food 

Insufficient  and  improperly  prepared  food 
is,  again,  a  recognized  predisposing  cause  of 
tuberculosis,  and  it  requires  no  argument  to 
establish  this  fact.  It  is,  however,  less  obvi- 
ous that  food,  in  order  to  nourish  the  body- 
properly  and  enable  it  to  maintain  its  working 
and  resisting  efficiency,  must  consist  of  the 
proper  ingredients  and  in  proper  proportions. 
We  must  have,  in  the  first  place,  the  proteids, 
the  most  important  variety  of  food,  which  are 
tissue-builders  and  repairers  of  the  body,  and 
which  are  furnished  by  both  the  animal  and 
vegetable  kingdoms,  examples  of  which  are 
meats  of  various  kinds,  milk,  cheese,  peas, 
bean's,  etc.  Secondly,  we  must  have  the  car- 
bohydrates, which  supply  heat  and  energy,  and 
are  usually  of  vegetable  origin,  such  as 
starches,  sugar,  cereals,  bread,  potatoes,  etc. ; 
and,  thirdly,  fats,  which  also  supply  heat  as 
well  as  fat — indeed,  they  are  the  most  impor- 
tant heat  producers.  The  Esquimaux,  who 
require  a  large  amount  of  body  heat  to  with- 
stand the  cold  of  their  Arctic  climate,  are  large 

72 


SEED   AND   SOIL 

consumers  of  fats.  Fats  are  obtained  both 
from  animal  and  vegetable  sources,  such  as 
the  fat  of  meat,  cream,  butter,  olive,  and  other 
vegetable  oils.  It  has  been  found  by  universal 
experience  that  a  mixed  diet  of  meat,  bread, 
milk,  eggs,  vegetables  containing  fat  and 
sugar  in  some  form,  will  best  furnish  these 
essential  principles. 

It  is  well  to  bear  in  mind  that  food  must 
not  only  be  nourishing,  but  be  prepared  in  a 
palatable  and  digestible  form :  hence  the  im- 
portance of  good  cooking.  Dettweiler,  the 
head  of  a  famous  sanatorium  in  Germany, 
used  to  say  that  his  pharmacy  was  his  kitchen, 
so  important  did  he  consider  the  food  and  its 
preparation  in  the  treatment  of  his  patients. 

Defective  Teeth 

Defective  teeth  are  a  very  real  predispos- 
ing cause  of  tuberculosis;  for  diseased  teeth 
in  themselves,  as  some  one  has  aptly  said, 
"  become  human  culture  tubes  with  ideal  cul- 
ture mediums  for  the  germs  of  disease " ; 
they  also  interfere  with  nutrition  through  in- 
complete mastication.  When  nutrition  fails, 
the  body's  resistance  to  disease  is  reduced. 
"  Defective   teeth,"   says   Dr.    Osier,   "  cause 

73 


TUBERCULOSIS 

more  physical  deterioration  than  does  alco- 
hol " ;  and  Professor  Jessen  of  Strassburg  de- 
clares that  "  the  tuberculosis  question,  in  addi- 
tion to  unhygienic  dwellings,  insufficient  sup- 
ply of  air  and  light,  is  a  question  of  nutrition, 
and,  therefore,  a  healthy  mouth  is  an  essential 
first  condition."  The  practical  deduction  from 
this  is  that  the  mouth  and  teeth  should  be 
kept  in  good  condition,  and  the  food  thor- 
oughly masticated  as  the  first  and  perhaps 
most  important  step  in  digestion.  Good  diges- 
tion means  good  resistance  to  disease. 

Alcohol  Makes  the  Bed  of  Tuberculosis 

Excesses  of  all  kinds,  particularly  in  the 
use  of  alcohol,  lower  the  vitality  and  prepare 
the  favorable  soil  for  tuberculosis.  The 
French  physicians  attribute  the  great  preva- 
lence of  tuberculosis  in  that  country  to  two 
principal  causes,  overcrowding  and  the  abuse 
of  alcohol.  Professor  Landouzy  says  that 
"  alcohol  makes  the  bed  of  tuberculosis " ; 
and  another  French  professor,  Brouardel,  de- 
clares that  "  alcoholism  is,  in  fact,  the  most 
powerful  factor  in  the  propagation  of  tuber- 
culosis. The  most  vigorous  man,  who  be- 
comes alcoholic,  is  without  resistance  before 

74 


SEED   AND   SOIL 

it."  In  the  case  of  two  hundred  and  thirty- 
two  consumptives  under  the  writer's  observa- 
tion, 41  per  cent,  gave  a  history  of  the  exces- 
sive use  of  alcohol.  Dr.  Newsholme,  of  Eng- 
land, who  has  made  a  very  exhaustive  investi- 
gation of  the  causes  of  tuberculosis,  says  that 
it  is  fairly  clear  that  there  is  an  excessive 
death  rate  from  consumption  among  intem- 
perate persons.  Physicians  have  long  recog- 
nized the  fact  that  those  who  use  alcohol,  even 
moderately,  have  less  resistance  to  infectious 
diseases;  and  in  the  modern  treatment  of 
tuberculosis,  alcohol  finds  very  little  place. 

Injurious  Occupations 

There  are  certain  occupations  which  seem 
particularly  prone  to  predispose  those  who 
follow  them,  to  tuberculosis;  this  they  do 
probably  both  by  their  influence  upon  the 
lung  tissue  itself  as  well  as  upon  the  general 
health.  Those  employed  where  there  is  much 
dust,  such  as  stone-cutters,  knife-grinders,  pot- 
ters, dyers,  wool-carders,  cigarmakers,  polish- 
ers, and  the  like,  especially  where  the  work  is 
carried  on  in  confined  spaces,  have  always 
suffered  a  large  mortality  from  tuberculosis. 
It  has  been  calculated  that  forty  thousand  or 

75 


TUBERCULOSIS 

more  deaths  occurred  annually  in  England 
and  Wales  among  those  thus  employed.  Mr. 
Hoffman,  the  statistician  of  the  Prudential 
Life  Insurance  Company,  in  an  analysis  of 
22,987  deaths  from  all  causes  in  those  engaged 
in  dusty  occupations,  found  that  the  propor- 
tionate mortality  from  consumption  was  28.0 
per  cent,  of  the  mortality  from  all  causes  at 
ages  fifteen  and  over,  while  among  men  in 
agricultural,  transportation,  and  other  outdoor 
occupations,  the  consumption  death  rate  was 
only  9.5  per  cent,  of  the  mortality  from  all 
causes.  "  If,"  he  says,  "  the  consumption 
mortality  in  dusty  trades  could  be  reduced  to 
the  corresponding  proportion  for  men  in  out- 
door occupations,"  which  he  believes  is  possi- 
ble, "  a  very  large  number  of  lives  would  be 
saved  and  continue  for  many  years,  which  are 
now,  to  a  large  extent,  needlessly  wasted." 
Printers,  compositors,  dressmakers,  bakers, 
and  those  who  work  where  smoke  and  irritat- 
ing gases  are  generated  contract  tuberculosis 
readily.  Teamsters  and  hack-drivers  are  also 
frequent  sufferers  from  tuberculosis  in  spite 
of  their  outdoor  life,  probably  from  their  ir- 
regularity of  living  and  alcoholism,  for  it  has 

76 


SEED    AND    SOIL 

been  observed  that  employments  which  are 
associated  with  temptations  to  the  abuse  of. 
alcohol  have  a  high  death  rate  from  consump- 
tion. 

In  certain  factories  and  workshops  where 
the  employees  are  crowded  together  in  a  con- 
fined atmosphere  and  when  there  is  an  absence 
of  sufficient  light,  tuberculosis  is  frequent. 
Probably  two  causes  are  at  work  under  these 
conditions:  In  the  first  place,  the  vitality  is 
lowered  by  the  existing  unwholesome  influ- 
ences in  such  workshops,  and  thus  the  suitable 
soil  is  prepared ;  and,  secondly,  there  is  always 
the  danger  that  some  workman  may  be  tuber- 
culous and  infect  his  fellow-workmen  if  he  is 
not  careful  to  destroy  or  safely  dispose  of  his 
sputum, — ^the  seed  is  present.  The  following 
case  illustrates  this  danger:  In  a  small  and  ill- 
ventilated  portion  of  a  counting-house  con- 
taining twenty-two  employees  there  came  two 
tuberculous  persons,  coughing  and  expecto- 
rating often  upon  the  floor.  The  employees 
came  early  in  the  morning  to  work,  when  the 
air  of  the  place  was  filled  with  dust  from  the 
daily  sweeping.  Within  five  years  thirteen  of 
these  employees  died  of  tuberculosis. 

77 


TUBERCULOSIS 

Over-Fatigue  and  Over-Exertion 

Over-fatigue,  overv^ork,  and  over-exertion, 
as  v^ell  as  insufficient  rest  and  sleep,  again 
lower  one's  resisting  pov^er  to  disease  and  help 
prepare  the  suitable  soil.  "  To  my  mind," 
says  Dr.  Burton-Fanning,  "  there  are  few 
causes  more  powerful  to  determine  the  out- 
break of  pulmonary  tuberculosis  than  physical 
over-exertion."  "  I  have  been  struck,"  he 
continues,  "  by  the  frequency  with  which  con- 
sumption attacks  men  who  have  distinguished 
themselves  in  various  athletic  pursuits.  This 
remark  particularly  applies  to  such  sports  as 
tax  the  power  of  endurance,  such  as  long- 
distance bicycle  riding  or  running,  rowing,  or, 
in  fact,  any  exhausting  exercise.  It  is  impor- 
tant to  recognize  that,  although  such  exercise 
be  taken  in  the  open  air,  it  is  conducive  to  the 
development  of  consumption  if  it  entail  ex- 
haustion or  fatigue.  Still  more  is  this  the 
case  if  the  exertion  be  undertaken  in  vitiated 
atmospheres,  and  the  debilitating  effects  of 
impure  air  be  added  to  that  of  strain.  Many 
consumptives  bring  on  their  diseases  by  per- 
sistent neglect  of  rest,  by  working  too  hard 
during  the  day  perhaps  and  taking  it  out  of 
themselves   with   pleasure   in   the   evenings." 

78 


SEED   AND   SOIL 

A  case  illustrative  of  the  above  recently  oc- 
curred in  the  author's  experience :  A  young 
man  living*  under  exceptionally  good  hygienic 
conditions  developed  tuberculosis ;  in  seeking 
the  predisposing  cause,  it  was  found  that  be- 
sides doing  an  exacting  day's  work,  he  was 
obliged  to  make  a  considerable  journey  twice 
daily  to  and  from  his  work,  and  thus,  as  he 
confessed,  he  was  in  a  constant  state  of  over- 
fatigue. 

Worry 

Worry  is  still  another  predisposing  cause, 
for  it  depresses  the  nervous  system,  which 
interferes  with  the  healthy  normal  functions 
of  the  body,  and  this  reduces  its  power  of 
resistance.  In  the  treatment  of  the  disease 
in  sanatoriums,  it  has  been  found  that  patients 
fail  to  improve  or  retrograde  if  their  minds 
are  not  at  ease,  and  they  worry  over  the  family 
left  at  home  or  some  other  real  or  imaginary 
trouble.  Contentment  of  mind  is  an  essential 
condition  for  the  maintenance  of  a  good  bodily 
condition.  The  man  who  worries  or  whose 
mind  is  overburdened  with  care  is  preparing 
a  fruitful  soil  for  the  tubercle  bacillus,  like 
Cassius  of  the  "  lean  and  hungry  look,"  who 

79 


TUBERCULOSIS 

"thinks  too  much,"  who  "loves  no  plays/* 
and  "  hears  no  music,"  who  "  seldom  smiles," 
and  "  scorns  the  spirit  that  could  be  moved  to 
smile  at  anything."  He  is  in  a  receptive 
condition  either  for  an  invading  infectious 
germ,  or  a  great  tragedy,  as  in  the  case 
of  the  ill-starred  Cassius.  Peace  of  mind 
and  contentment  are  as  essential  for  the 
body  as  the  spirit.  "  A  merry  heart  doeth 
good  like  a  medicine :  but  a  broken  spirit  dri- 
eth  the  bones." 

Monotony  of  Occupation 

Monotony  of  life  exercises  a  depressing  in- 
fluence upon  the  body,  and  therefore  acts  as 
a  predisposing  cause  to  tuberculosis.  In  the 
industrialism  of  the  present  day  when  the 
workman  or  operative  performs  a  single  act 
over  and  over  again  in  the  manufacture  of 
any  article,  the  monotony  of  it  becomes  de- 
pressing. So  with  the  housewife  whose  daily 
round  of  household  duties  is  ever  the  same 
and  never  done.  To  obviate  the  evil  and  de- 
pressing influence  of  such  monotonous  occu- 
pations, diversion  and  amusement  must  be 
afforded,  so  that  one  may  forget  for  an  hour 
that  he  is  a  cog  in  the  wheel  of  the  great 

80 


SEED   AND   SOIL 

machine,  and  thus  refreshed  in  mind  he  can 
return  to  his  labor  with  renewed  vigor  to 
endure  the  monotonous  round  of  his  existence. 
To  provide  clean  amusement  for  the  people 
is  an  hygienic  measure  of  the  first  importance. 
To  have  a  healthy  body  we  must  have  a 
healthy  mind. 

Tuberculosis  has  been  well  called  the 
"  disease  of  the  masses,"  for  it  thrives  upon 
human  misery  and  poverty.  The  tenement 
house  with  all  its  evils  of  overcrowding; 
want;  excessive  hours  of  labor;  absence  of 
fresh  air  and  sunlight;  alcohol,  often,  alas! 
the  only  solace  and  diversion  of  the  poor  man, 
vie  with  each  other  in  preparing  a  fertile  soil 
for  the  deadly  tubercle  bacillus.  Any  and 
every  measure  which  makes  for  the  improved 
living  conditions  of  the  masses  is  a  redoubt- 
able foe  to  all  these  many  predisposing  influ- 
ences. We  must  render  the  soil  sterile  as 
well  as  control  the  seed. 


8i 


VI.    THE  RECOGNITION  AND  SYMP- 
TOMS OF  TUBERCULOSIS 

INCE  the  discovery  of  the  cause 
of  tuberculosis,  the  study  of  the 
disease  has  been  renewed  with 
great  vigor  and  interest.  Par- 
ticularly is  this  the  case  in  the 
endeavor  to  discover  it  at  an  early  stage,  when 
it  is  just  beginning,  and  when  it  can  be  treated 
with  the  greatest  probability  of  success.  In 
earlier  times  tuberculosis  was  not  generally 
detected  until  it  had  made  considerable  prog- 
ress and  was  in  what  we  should  now  call  a 
more  or  less  advanced  stage,  and  when  it  had 
seriously  affected  the  general  health.  By  a 
careful  study  of  the  symptoms  and  by  im- 
proved methods  and  greater  skill  in  physical 
examination,  the  physician  can  generally  rec- 
ognize the  disease  at  an  early  period.  Unfor- 
tunately, however,  many  persons  suffering 
from  it  are  all  unconscious  of  the  fact  and  do 
not  seek  the  physician  until  the  disease  is 
advanced   and  the  most   favorable   time   for 

82 


SYMPTOMS 

treatment  has  passed.  Hence  the  great  im- 
portance of  seeking  an  examination  if  some  or 
any  of  the  suspicious  symptoms  are  present 
which  one  can  easily  detect,  and  which  sug- 
gest the  possibiHty  of  tuberculosis. 

Early   Symptoms 

Such  symptoms  are  a  slight  hacking  cough, 
perhaps  only  occurring  in  the  morning,  and 
which  persists,  accompanied  with  a  slight 
amount  of  expectoration, — one  often  deceives 
himself  by  regarding  such  a  cough  as  only  a 
slight  "  cold," — a  loss  of  weight  and  strength, 
and  a  general  feeling  of  debility  so  that  one 
does  not  feel  "  up  "  to  his  work ;  a  loss  or 
impairment  of  the  appetite;  slight  fever  in  the 
afternoon,  perhaps  preceded  by  chilly  sensa- 
tions ;  breathlessness  on  exertion ;  and  some- 
times "  night  sweats."  In  the  past  many  cases 
of  consumption  were  mistaken  for  malaria, 
bronchitis,  the  "  grippe,"  or  only  dyspepsia, 
and  so  went  on  in  a  false  security  until  finally 
the  sad  awakening  came  and  the  disease  was 
found  to  be  advanced.  Bleeding  from  the 
lungs,  which  is  called  "  haemoptysis,"  may  be 
the  first  symptom  which  calls  attention  to 
tuberculosis;   and  it  is   sometimes   fortunate 

83 


TUBERCULOSIS 

that  this  symptom  which,  in  the  early  stage, 
is  not  so  serious  as  alarming,  occurs  in  the 
beginning  of  the  disease,  for  the  patient  in 
his  alarm  hurries  to  the  physician,  and  thus 
the  disease  is  discovered  at  an  early  period 
and  timely  treatment  begun. 

It  is  interesting  to  know  how  the  physician 
goes  to  work  to  make  what  is  called  a  **  physi- 
cal examination  "  of  the  lungs.  He  first  be- 
gins by  "  inspection,"  looking  at  the  bare  chest 
of  the  patient  and  observing  its  shape,  irregu- 
larities, and  its  movements  in  breathing. 
Sometimes  one  side  of  the  chest  will  have 
less  movement  in  respiration  than  the  other, 
which  suggests  that  on  the  side  of  less  move- 
ment there  may  be  some  tuberculous  deposits 
which  restrict  the  respiratory  movement. 
Again,  the  physician  may  notice  that  there  is 
a  slight  depression  at  the  top  or  apex  of  one 
side  of  the  chest,  which  again  suggests  tuber- 
culosis. After  obtaining  all  the  information 
he  can  by  inspection,  the  physician  next  pro- 
ceeds to  employ  the  two  most  valuable  meth- 
ods of  physical  examination,  called  "  percus- 
sion "  and  "  ausculation,"  which  depend  upon 
the  resonant  quality  of  the  lungs,   and  the 

84 


SYMPTOMS 

sounds  which  are  produced  in  them  by  the  act 
of  breathing,  or  talking. 

How  the  Lungs  Are  Tested 

The  method  of  "  percussion "  or  tapping 
with  the  finger  or  an  instrument,  like  a  little 
hammer,  upon  the  chest  wall,  sometimes  called 
"  sounding "  the  chest,  was  discovered  long 
ago  by  a  Viennese  physician  named  Auen- 
brugger,  who  published  his  discovery  in  176 1 
in  a  little  book  written  in  Latin,  entitled  the 
"  New  Invention."  In  the  preface  he  says :  "  I 
present  to  you,  charitable  reader,  a  new  sign 
which  I  have  discovered  for  detecting  diseases 
of  the  chest.  This  consists  in  the  percussion 
of  the  human  thorax,  from  the  varying  reso- 
nance of  the  sounds  of  which  an  opinion  can 
be  formed  of  the  internal  condition  of  this 
cavity."  For  forty-seven  years  this  inestima- 
ble discovery  of  Auenbrugger  seems  to  have 
been  lost  sight  of,  when  Corvisart,  a  French- 
man, who  was  the  physician  of  Napoleon,  re- 
discovered it  and  translated  Auenbrugger's 
little  book  into  French  in  1808.  From  that 
time  to  the  present  percussion  has  been  in 
constant  use  by  physicians,  and  will  always 

85 


TUBERCULOSIS 

remain  a  method  of  the  greatest  value  in 
examining  the  chest. 

"  Auscultation/'  "  that  wonderful  art  of 
discovery  of  disease,"  says  Dr.  Oliver  Wendell 
Holmes,  "  which,  as  it  were,  puts  a  window 
in  the  breast  through  which  the  vital  organs 
can  be  seen  to  all  intents  and  purposes,"  was 
discovered  by  a  French  physician,  Laennec, 
who  published  a  treatise  upon  it  in  1819. 
"  Before  Laennec,"  says  some  one,  "  clinical 
observation,  though  never  blind,  had  been  al- 
ways deaf."  By  auscultation  we  are  enabled 
to  listen  to  the  sounds  of  breathing  and  the 
voice  sounds  as  they  are  re-echoed  in  the 
chest,  and  also  to  detect  other  abnormal  sounds 
which  disease  causes  in  the  lungs.  When 
one  is  familiar  with  the  normal  sounds  of 
breathing  and  of  the  voice,  he  is  enabled  to 
determine  when  these  sounds  are  changed  by 
disease  or  when  other  sounds  not  present  in 
health  occur.  Thus,  the  physician  can  by  ex- 
perience tell  the  peculiar  sounds,  and  modifica- 
tions of  the  normal  sounds,  which  are  pro- 
duced when  there  are  tuberculous  masses  in 
the  lungs,  if  these  masses  are  large  enough  to 
affect  the  normal  sounds. 

In   practicing   auscultation   an    instrument 

86 


THEOPHILE    LAENNEC, 
Discoverer  of  Auscultation. 


SYMPTOMS 

called  the  stethoscope  is  employed,  one  end 
of  which  is  applied  to  the  patient's  chest  and 
the  other  to  the  physician's  ears.  Laennec, 
who  made  the  first  stethoscope,  which  was 
simply  a  hollow  wooden  cylinder  a  foot  long, 
thus  happened  upon  this  invaluable  discovery : 
He  was  one  day  consulted  by  a  stout  young 
woman  with  symptoms  of  heart  disease.  On 
account  of  her  stoutness  and  her  age  and  sex, 
he  was  prohibited,  he  says,  from  applying  his 
ear  directly  to  her  chest.  Taking  up  a  quire 
of  paper  from  his  desk,  he  made  a  tight  roll 
and  applied  one  end  of  it  to  the  chest  of  the 
young  girl  and  the  other  to  his  ear.  With 
delight  he  found  that  in  this  way  he  per- 
ceived much  more  plainly  the  beating  of  the 
heart. 

"  What  millions  of  physicians,"  says  a 
writer  upon  Laennec,  "  must  have  attended 
millions  upon  millions  of  chest  disease  between 
Hippocrates  and  Laennec,  and  yet  Laennec 
was  the  man  and  mind  wanted  to  make,  or 
rather  to  complete,  a  discovery  that  had  been 
lying  ready  for  birth  some  thousands  of  years. 
It  waited  for  the  fat  young  lady  with  heart 
disease  whose  chest  could  not  be  touched  by 
ears  polite,  for  the  quire  of  paper  that  ad- 

87 


TUBERCULOSIS 

mitted  of  being  rolled  into  a  tube  for  listening 
through,  and  for  this  man  Laennec  to  do 
the  part  of  thoracic  eavesdropper." 

It  seems  the  irony  of  fate  that  Laennec, 
who  devoted  his  life  and  genius  to  the  study 
and  detection  of  tuberculosis,  should  have 
himself  died  of  this  disease  at  the  age  of  forty- 
five;  but  his  work  lives  after  him,  and  every 
time  the  physician  uses  the  invaluable  method 
of  auscultation  and  applies  his  stethoscope  to 
the  patient's  chest  he  thinks  with  gratitude  of 
this  renowned  Frenchman  who,  for  the  good 
of  humanity,  placed  this  means  of  examination 
in  his  hands. 

It  requires  a  keen  ear  and  one  accustomed 
to  detect  slight  variations  in  the  pitch  and  tone 
of  sounds  to  be  successful  in  percussion  and 
auscultation,  and  it  is  not  surprising  to  learn 
that  both  Auenbrugger  and  Laennec  were 
lovers  of  music.  Indeed,  Laennec  was  a  mu- 
sician and  played  upon  the  flute,  while  Auen- 
brugger attuned  his  ear  by  listening  to  good 
music.  Of  all  the  methods  of  physical  exami- 
nation of  one  suspected  of  having  tuberculosis, 
percussion  and  auscultation  are  the  most  valu- 
able, for  they  "  enable  us  in  many  cases,"  as 
Dr.  Holmes  so  wisely  says,  "  to  distinguish 

88 


SYMPTOMS 

phthisis  (tuberculosis)  before  its  existence  is 
shown  by  the  general  symptoms,  at  a  period 
when  we  can  say,  do  this  and  you  may  live, 
do  that  and  you  must  die."  Not  infrequently, 
however,  we  are  unable  to  determine  the  ex- 
istence of  tuberculosis  by  the  most  painstaking 
physical  examination;  but  our  resources  are 
not  yet  at  an  end.  We  have  other  valuable 
aids. 

Examination  of  the  Sputum 

The  first  is  one  which  is  always  employed 
by  physicians  when  possible,  that  is,  when  any 
expectoration  can  be  obtained,  which  is  not 
always  the  case  in  the  very  early  stage  of  the 
disease:  it  is  the  examination  of  the  sputum, 
to  see  if  there  are  the  germs  of  tuberculosis, 
the  tubercle  bacilli,  in  it.  By  means  of  cer- 
tain staining  fluids  we  can  color  the  tubercle 
bacilli,  which  will  retain  the  stain  when  it  is 
washed  away  from  the  other  portion  of  the 
sputum.  When  the  sputum  is  so  prepared  and 
placed  under  the  microscope,  the  bacilli,  if 
they  are  present,  are  seen  as  tiny  red  rods. 
So  characteristic  are  they  that  when  once  ac- 
customed  to  their  appearance,  they  cannot  be 
mistaken. 

89 


TUBERCULOSIS 

When  the  bacilli,  or  tuberculosis  germs,  are 
found  in  the  sputum,  it  is  a  sure  proof  that  tu- 
berculosis exists;  but  not  infrequently,  in  the 
very  beginning  of  the  disease,  and  also  when  it 
is  more  advanced  in  certain  cases,  the  germs 
are,  for  one  reason  or  another,  not  found,  so 
that  we  are  not  justified  in  saying  that  there  is 
no  tuberculosis  when  this  is  the  case  if  there 
are  other  symptoms  and  signs  of  the  disease. 
We  must  then  turn  to  other  tests.  So  impor- 
tant, however,  is  the  examination  of  the  spu- 
tum, vv^hich,  when  successful,  or  "  positive," 
as  we  say,  is  an  absolute  proof  of  tuberculosis, 
that  state  and  city  boards  of  health  now  main- 
tain free  laboratories  to  which  physicians  can 
send  the  sputum  of  a  suspected  case  of  tuber- 
culosis and  have  it  examined  by  an  expert. 
All  medical  students  also  are  now  taught  to 
make  the  sputum  examination  for  tuberculosis 
in  the  interest  of  their  future  patients. 

The   Tuberculin   Test 

Another  modern  aid  is  the  "  tuberculin  test." 
We  have  already  spoken  of  tuberculin  in  the 
previous  chapter,  and  it  is  this  same  tuberculin 
which  is  employed  in  making  the  tuberculin 
test.     A  very  minute   quantity  is  either  in- 

90 


SYMPTOMS 

jected  into  the  suspected  individual,  or  he  is 
vaccinated  with  it  much  as  we  vaccinate  for 
small-pox,  or  a  drop  of  a  very  dilute  solution 
is  put  in  the  eye.  If  tuberculosis  exists  any- 
where in  the  body,  we  generally  obtain  a  "  re- 
action," as  it  is  called,  in  the  case  of  an  injec- 
tion ;  or,  if  used  by  vaccination  or  in  the  eye, 
certain  characteristic  appearances  are  ob- 
served. This  test  is  not  always  sure,  but  it 
is  a  very  great  aid  in  detecting  early  tubercu- 
losis. Long  and  large  experience  with  the  use 
of  tuberculin  in  this  way  has  proved  that  it  is 
not  injurious  if  carefully  applied  by  the  physi- 
cian. 

The  tuberculin  test  is  also  used  with  great 
success  in  the  testing  of  cattle,  especially  cows, 
and  is  now  generally  employed  with  dairy 
herds  in  order  to  safeguard  the  milk. 

So  the  world  is  not  only  indebted  to  Pro- 
fessor Koch  for  the  discovery  of  the  cause  of 
tuberculosis,  but  for  this  very  valuable  aid 
in  detecting  it  at  an  early  period. 

The  X-Ray 

Still  another  aid  in  the  detection  of  tubercu- 
losis is  the  X-Ray,  now  so  generally  known 
and  used,  particularly  by  surgeons.    By  means 

91 


TUBERCULOSIS 

of  this  wonderfully  penetrating  light  we  can 
actually  look  through  the  body,  and  it  becomes 
almost  as  transparent  as  was  Marley's  ghost 
when  old  Scrooge,  in  Dickens'  "Christmas 
Carol,"  looked  through  it  as  it  stood  in  his 
bed  chamber  and  saw  the  two  buttons  on  its 
coat  behind.  The  lungs  in  health  are  quite 
translucent  to  the  X-Ray  light,  but  when 
there  is  tuberculosis  in  them,  a  dark  shadow 
appears,  the  tuberculosis  deposit  prevents  the 
light  from  penetrating  them.  So  by  the 
X-Ray  picture  we  can  often  detect  evidences 
of  tuberculosis  which  cannot  be  discovered 
by  the  other  methods  of  examination. 

By  having  at  our  command  all  these  vari- 
ous methods  of  examination  and  by  carefully 
taking  into  account  all  the  symptoms,  we  are 
enabled  almost  always  to  recognize  pulmonary 
tuberculosis  in  its  commencement  or  at  least 
strongly  suspect  it  and  so  begin  the  treatment 
when  there  is  every  hope  of  cure.  With  chil- 
dren the  detection  of  tuberculosis  is  generally 
more  difficult  than  with  adults,  for  among  other 
difficulties,  they  do  not  expectorate  and  we 
cannot  have  the  help  which  the  sputum  exam- 
ination affords.  With  all  the  methods  of 
examination,  however,  and  the  skill  of  the  phy- 

92 


SYMPTOMS 

sician,  the  disease  is  more  frequently  discov- 
ered in  children  than  formerly,  and  it  has  been 
shown  that  it  is  far  more  prevalent  in  them 
than  was  previously  supposed. 

Closed  Tuberculosis 

It  has  been  said  above  that  sometimes  in 
the  beginning  of  tuberculosis  the  germs  are 
not  found  in  the  sputum,  and  it  is  also  true 
that  in  some  of  these  early  cases  there  is  no 
sputum.  We  call  such  cases  "  closed  "  tuber- 
culosis. If,  therefore,  we  can  detect,  treat 
and  cure  these  "  closed "  cases  before  they 
become  "open,"  or  have  sputum  containing 
germs,  we  protect  the  community  by  just  so 
much  from  the  dangers  of  contracting  the 
disease.  For  such  cases,  if  they  were  allowed 
to  go  on  and  become  "  open,"  or  communi- 
cable, and  if  they  did  not  properly  destroy 
their  sputum,  would  give  the  disease,  it  is  esti- 
mated, to  three  times  as  many  more  on  an 
average. 

The  Only  Safe  Way 

In  the  very  beginning  of  tuberculosis,  there 
are  frequently  few,  if  any,  symptoms,  and  the 
individual  does  not  feel  really  ill.     How,  then, 

93 


TUBERCULOSIS 

is  he  to  know  that  he  is  in  any  danger,  and 
seek  an  examination  of  his  lungs?  The  only 
safe  way  is  occasionally  to  have  one's  lungs 
examined,  particularly  if  there  has  been  any 
exposure  to  the  disease,  as  in  a  family  where 
some  member  is  suffering  from  it.  School 
children  and  students  should  be  periodically 
examined,  particularly  on  graduation  from 
school  or  college,  for  if  any  evidence  of  tuber- 
culosis was  shown,  advice  with  regard  to  the 
choice  of  an  occupation  would  be  of  inestima- 
ble value.  How  many  young  lives  just  be- 
ginning their  career  might  have  been  saved 
from  an  untimely  ending  through  tuberculosis 
if  this  plan  had  been  followed ! 

In  the  same  way,  if  all  operatives  in  work- 
shops and  factories,  employees  in  department 
stores  and  clerks  could  receive  a  periodic 
examination  of  their  lungs,  many  lives  would 
be  saved,  and  those  associated  with  them 
would  be  protected  from  the  possibilities  of 
contracting  the  disease.  When  we  remember 
that  from  one-fourth  to  one-third  of  all  deaths 
between  the  ages  of  fifteen  and  forty-five  or 
fifty  years  are  caused  by  tuberculosis,  there 
is  the  very  greatest  reason  why  all  persons 
during  this  age  should  from  time  to  time  have 

94 


SYMPTOMS 

their  lungs  examined.  If  such  a  mortality 
as  now  occurs  from  tuberculosis  was  known 
to  exist  from  a  single  disease  among  a  choice 
breed  of  cattle,  horses,  sheep,  or  what  not,  how 
quickly  would  the  owners  use  every  protective 
means  to  safeguard  their  stock.  "  How  much 
then  is  a  man  better  than  a  sheep  " ! 

There  are  many  difficulties  in  discovering 
tuberculosis  at  an  early  period  among  wage- 
earners  and  the  poor.  In  the  first  place,  the 
workingman  cannot  afford  to  give  up  his 
work  until  actually  disabled ;  and,  again,  he  is 
often  ignorant  of  the  meaning  of  his  symp- 
toms, or,  if  he  does  suspect  that  he  has  tuber- 
culosis, he  fears  that  its  discovery  may  lead 
to  the  loss  of  his  occupation  and  hence  the 
livelihood  of  himself  and  family.  Finally,  if 
he  has  to  pay  for  his  examination,  he  may  not 
have  the  means  to  do  this. 

To  obviate  this,  there  are  now  established 
all  over  the  civilized  world — and  their  number 
is  being  daily  increased — free  tuberculosis  dis- 
pensaries where  a  reliable  examination  of  the 
lungs  can  be  obtained  without  expense  to  the 
poor  man.  These  beneficent  institutions  in 
connection  with  the  popular  dissemination  of 
the  simple  truths  concerning  tuberculosis  are 

95 


TUBERCULOSIS 

of  the  highest  value  in  securing  to  the  work- 
ingman  an  early  examination  of  his  lungs. 

In  connection  with  such  dispensaries  there 
are  trained  nurses,  social  workers,  or  visitors 
who  visit  every  home  where  a  case  of  tuber- 
culosis is  found  to  exist,  and  who,  besides  ad- 
vising the  consumptive  member  how  to  prop- 
erly conduct  his  life  so  as  to  avail  himself  of 
all  his  chances  of  recovery,  if  he  is  treated  at 
home,  urges  all  the  other  members  of  the 
household  to  go  to  the  dispensary  for  an  exam- 
ination. In  this  way,  many  early  cases  of  tu- 
berculosis are  discovered  and  thus  we  are 
enabled,  as  Dr.  Pryor  has  so  well  and  epigram- 
matically  said,  "  to  care  for  the  consumptive  in 
the  right  place,  in  the  right  way,  and  at  the 
right  time  until  he  is  cured;  instead  of  in  the 
wrong  place,  in  the  wrong  way,  at  the  wrong 
time  until  he  is  dead." 

Points  to  Remember 

Consumption  is  curable  in  the  larger  num- 
ber of  cases  if  treated  at  an  early  stage. 
Hence,  an  early  detection  of  the  disease  is  of 
the  very  greatest  importance;  and  among  the 
earlier  symptoms  which  anyone  can  observe 

96 


SYMPTOMS 

(and,  finding*  which,  he  should  at  once  seek 
the  physician)  are: 

(a)  A  slight  cough,  or  a  cold,  lasting:  a 
month  or  more. 

(b)  Loss  of  weight. 

(c)  Slight  fever  in  the  afternoon. 

(d)  Loss  of  strength,  or  a  tired  feeling. 

(e)  Shortness  of  breath  on  exertion. 

(f)  Loss  or  impairment  of  appetite. 

(g)  Bleeding  from  the  lungs. 

A  wise  English  physician  gives  this  advice 
to  doctors :  "  Always  say  three  things  to  a 
patient  whom  you  suspect  to  be  phthisical 
(tuberculosis)  : 

"(i)  *Get  yourself  weighed — by  the  same 
machine  each  time — to  see  if  you  are  losing 
weight.' 

(2)  '  Use  a  thermometer  two  or  three 
times  each  evening,  to  see  if  there  is  any 
fever.' 

(3)  '  Save  your  sputa  to  be  tested  (for  ba- 
cilH).'" 


9^ 


VII.    THE    CURABILITY    OF   TUBER- 
CULOSIS   AND   ITS    TREATMENT 

GREAT  change  has  taken  place 
in  recent  times  in  the  opinion 
both  of  physicians  and  the  pubHc 
regarding  the  curability  of  tu- 
berculosis. As  was  stated  in  the 
conclusion  of  the  last  chapter,  tuberculosis  is 
now  regarded  as  one  of  the  most  curable  of 
chronic  diseases,  provided  the  treatment  is  be- 
gun early,  before  the  disease  has  made  any 
serious  inroads  upon  the  general  health  and 
constitution.  Experience,  that  infallible 
teacher,  extending  over  many  years,  has 
abundantly  verified  this  statement. 

Formerly  Regarded  as  Hopeless 

Formerly,  however,  tuberculosis  was  con- 
sidered well-nigh  hopeless  by  the  majority  of 
physicians,  principally  due  to  the  fact  that 
they  did  not  know  how  to  discover  it,  as  a 
rule,  until  it  had  reached  an  advanced  condi- 
tion. 

98 


CURABILITY   AND   TREATMENT 

Louis,  one  of  the  most  celebrated  French 
physicians,  declared  more  than  eighty  years 
ago  that  tuberculosis  was  a  well-nigh  hopeless 
disease,  and  almost  invariably  terminated 
fatally;  and  Dr.  Stoll,  an  old  English  physi- 
cian, speaks  of  an  eminent  divine  who  declared 
that  it  was  blasphemy  to  assert  that  the  dis- 
ease (tuberculosis)  was  curable,  "  for  God 
himself  had  made  it  incurable."  Dr.  James 
Jackson,  a  distinguished  physician  in  Boston 
in  his  day,  wrote  in  1855  that  consumption 
was  almost  uniformly  fatal;  and  Dr.  Wilson 
Fox  of  London,  as  late  as  1887,  declared  that 
complete  cures  of  consumption  was  a  rare 
event. 

From  the  time  of  Hippocrates  down  the 
ages,  however,  there  was  now  and  then  a  keen 
physician  who  declared  his  belief  in  the  cura- 
bility of  tuberculosis.  Hippocrates  himself 
believed  this.  Laennec,  of  whom  we  have  al- 
ready heard,  declared  that  the  cure  of  con- 
sumption when  the  lungs  are  not  completely 
diseased,  ought  not  to  be  looked  upon  as  at 
all  impossible ;  and  after  reviewing  the  various 
cures  suggested  at  that  time,  such  as  bleeding, 
blisters,  purgatives,  the  inhalation  of  different 
gases,  the  air  of  cow  houses,  acorns  roasted 

99 


TUBERCULOSIS 

or  raw,  mushrooms,  crabs,  oysters,  frogs, 
vipers,  emetics,  etc.,  finally  concludes  with  the 
following  wise  remark,  "  that  although  the 
cure  of  consumption  may  be  possible  for  na- 
ture, it  is  not  so  for  medicine."  Would  that 
the  last  part  of  this  sentence  was  always  kept 
in  mind  at  the  present  day,  for  even  now  many 
a  poor  consumptive  believes  that  medicine  or 
some  of  the  innumerable  quack  remedies  can 
cure  him'. 

Useless  Remedies 

Numberless  remedies  have  at  one  time  or 
another  been  extolled  and  applied,  often  to  the 
injury,  if  not  worse,  of  the  unfortunate  con- 
sumptive. A  hundred  years  ago,  emetics  and 
cathartics  were  a  popular  form  of  treatment 
of  tuberculosis,   as   of  many   other  diseases. 

Dr.  StoU  of  Hartford,  Conn.,  who  has  writ- 
ten a  very  interesting  account  of  the  early 
treatment  of  consumption,  quotes  a  Dr.  Parr 
as  saying,  "  Could  phthisis  (consumption) 
ever  be  cured  it  would  be  by  joint  action  of 
emetics  and  blisters  " ;  and  there  is  a  record 
of  a  woman,  aged  forty  years,  who  took  600 
emetics  in  ten  years.  The  result  of  this  heroic 
treatment  is  not  given,  but  it  is  not  difficult  to 
guess.    Bleeding  was  another  popular  method 

100 


CURABILITY   AND    TREATMENT 

of  treatment,  and  Dr.  StoU  refers  to  advice 
given  to  a  consumptive  to  ''  lose  six  ounces  of 
blood  each  day  for  a  fortnight,  if  he  lived  so 
long!''  Residence  in  a  cow  house  was  an- 
other treatment,  founded  on  the  theory  that 
the  "  vapors  "  and  heat  from  the  cows  were 
somehow  beneficial.  This  form  of  treatment, 
however,  did  not  seem  to  be  very  kindly  re- 
ceived, and  a  certain  physician  who  was  ac- 
customed to  advise  it,  remarks :  "  Not  infre- 
quently did  I  forfeit  the  good  opinion  of  my 
patients."  Almost  everybody  believed  night 
air  injurious  as  well  as  cold  air,  and  con- 
sumptives were  advised  to  shut  themselves  up 
in  the  house  during  the  coldest  months  of  the 
winter.  The  two  striking  features  in  the 
treatment  of  the  disease  during  the  last  cen- 
tury were  the  removal  of  the  patient  to  a 
milder  climate,  no  matter  what  the  stage  of 
the  disease,  and  the  use  of  cod  liver  oil. 
Multitudes  were  sent  away  to  die  far  from 
home,  and  the  nauseous  oil  destroyed  the  di- 
gestion of  not  a  few. 

The  True  Theory  of  Treatment 

Here  and  there,  however,  as  has  been  said, 
there  were  a  few  wise  physicians  who  believed 

lOI 


TUBERCULOSIS 

that  consumption  was  at  least  sometimes  cura- 
ble and  were  sagacious  enough  to  recognize 
that  the  essential  treatment  was  not  by  drugs 
and  depressing  measures,  but  by  supporting 
the  patient  and  increasing  his  resisting  powers. 
Thus,  in  1804,  there  was  a  Dr.  Stewart  of 
England,  who  was  both  a  clergyman  and 
physician,  whose  treatment  "  was  founded," 
as  one  of  his  patients  expressed  it,  "  upon 
every  principle  of  common  sense,"  and  who 
"  supported  the  constitution  and  enabled  it  to 
throw  off  the  disease  by  its  own  rallying 
powers."  In  1840  George  Bodington,  a  coun- 
try doctor  in  England,  presented  a  method  of 
treatment  to  his  medical  brethren  which  he 
called,  "  The  cure  of  pulmonary  consumption 
on  principles  natural,  rational  and  successful," 
and  established  a  sanatorium  in  which  he  car- 
ried out  his  treatment,  which  was  essentially 
the  "  open-air  method  "  of  to-day.  The  pub- 
lic, however,  was  not  ready  for  such  a  radical 
innovation  upon  the  old-established  drugging 
method,  and  bitterly  opposed  him,  as  did  his 
own  professional  colleagues.  His  patients 
forsook  him  and  he  was  finally  obliged  to  turn 
his  institution  into  an  insane  asylum,  and  he, 
indeed,  was  regarded  as  a  lunatic.     In  1855 

102 


CURABILITY   AND    TREATMENT 

Dr.  Henry  McCormac,  of  Belfast,  Ireland, 
wrote  a  book  in  which  he  advocated  a  similar 
method  of  treatment  to  that  of  Bodington's; 
but  he,  also,  met  the  fate  of  his  predecessor, 
and  was  bitterly  opposed  and  even  persecuted. 
Such  is  so  often  the  experience  of  those  who 
present  some  new  discovery  or  device  which  is 
contrary  to  the  accepted  opinions  of  the  times ; 
they  find  but  few  daring  spirits  who  are  will- 
ing to  investigate  with  open  mind  the  new 
ideas,  and  who  are  ready  to  accept  them  if 
they  offer  something  better  than  what  exists. 
Such  has  often  been  the  case  within  the  medi- 
cal profession  itself. 

Finally  Brehmer,  a  German  pioneer  in  the 
modern  treatment  of  tuberculosis,  established 
in  Goerbersdorf,  Germany,  the  first  sanato- 
rium, fifty  or  more  years  ago,  conducted  upon 
the  modern  principles  of  the  out-door  treat- 
ment, and  which  is  still  in  operation. 

Gradually  at  first,  and  later  more  rapidly, 
similar  sanatoria  have  sprung  up  in  almost 
every  civilized  country,  until  now  the  new  idea 
of  treatment  has  become  thoroughly  estab- 
lished. 

After  the  cause  of  tuberculosis  had  been 
proved  to  be  a  specific  germ — the  tubercle  ba- 

103 


TUBERCULOSIS 

cillus — there  was  a  new  search  begun  to  find 
a  specific  remedy  which  would  destroy  this 
germ  in  the  lungs  and  so  stop  the  disease.  It 
seems  to  be  an  instinct  in  human  nature  to  be 
ever  seeking  a  specific  remedy,  an  easy  cure, 
for  the  diseases  of  mankind;  to  swallow  a 
drug  seems  to  so  many  persons  a  much  more 
direct  and  easy  method  of  cure  than  the  slower 
and  more  certain  process  of  following  Na- 
ture's laws  and  correcting  errors  in  one's 
mode  of  life. 

At  first  some  substance  was  sought  for 
which  could  be  injected  into  the  lungs  and  kill 
the  bacillus,  but  nothing  has  ever  been  dis- 
covered which  will  do  this  without  killing  the 
patient.  Again,  various  antiseptics  have  been 
tried,  applied  in  one  way  or  another,  by  inhala- 
tions, vapors,  or  taken  internally,  for  the  same 
purpose  of  destroying  the  bacillus,  or  prevent- 
ing its  activity,  but  they  likewise  have  all 
failed.  Still  the  search  goes  on  and  hardly 
a  week  passes  that  some  new  specific  is  not 
extolled  as  a  "  sure  cure "  for  consumption, 
but,  Hke  Job's  friends,  they  are  all  "  miserable 
comforters  " ;  they  have  their  little  day,  fail, 
and  pass  into  oblivion. 

The  only  treatment  which  has  stood  the 
104 


CURABILITY   AND   TREATMENT 

test  of  time  and  the  one  universally  employed 
at  the  present  day  is  the  so-called  "  open-air 
treatment."  When  it  is  recalled  that  in  for- 
mer times  the  unfortunate  consumptive  was 
confined  in  a  closed  room,  so  great  was  the 
fear  of  taking  more  cold  (for,  because  the 
cough  was  the  most  prominent  symptom,  it 
was  really  regarded  as  the  disease  itself),  it 
will  be  realized  how  radical  a  change  from 
this  old  method  is  the  new  one  of  the  out-door 
life. 

The   Out-Door   Treatment 

The  principle  of  the  "  open-air  treatment " 
is  simple  and  consists  in  re-establishing  the 
power  of  resistance  of  the  consumptive  by  in- 
creasing his  vital  powers, — in  brief,  to  pro- 
duce and  maintain  a  high  degree  of  bodily 
health.  The  whole  treatment  is,  in  a  sense, 
an  indirect  one,  a  treatment  of  the  individual 
rather  than  of  the  disease.  As  in  the  case  of 
so  many  other  diseases  for  which  we  have  no 
specific  remedy,  it  is  simply  putting  the  con- 
sumptive in  the  most  favorable  condition  to 
fight  his  own  disease;  it  is  developing  to  the 
highest  degree  his  "  natural  immunity,"  of 
which  we  have  before  spoken.     This  seems 

105 


TUBERCULOSIS 

very  plain  and  easy  in  the  statement,  but  it 
really  requires  much  patience  and  power  of 
will  to  adhere  rigorously  to  a  strict  daily 
routine  of  living,  extending  over  a  consider- 
able period  of  time,  even  for  years,  it  may  be, 
in  some  cases. 

There  are  four  essential  requisites  in  this 
treatment : 

(i)  Competent  and  continued  medical 
supervision.  The  physician  must  plan,  direct 
and  supervise  the  daily  life  of  the  consump- 
tive. No  one  should  undertake  the  treatment 
without  being  in  touch  with  a  competent 
physician. 

(2)  Continuous  out-door  life.  The  con- 
stant and  continuous  exposure  of  the  patient 
to  pure  out-door  air  night  and  day.  During 
the  day  the  patient  remains  out-of-doors, 
either  at  rest  in  a  reclining  chair,  like  a  ship's 
chair,  or,  later  in  the  course  of  the  treatment, 
taking  a  limited  amount  of  exercise  on  the 
advice  of  the  physician  only.  If  there  is 
fever,  even  a  little  rise  of  temperature,  abso- 
lute rest  is  required.  At  night,  one  either 
sleeps  directly  out  of  doors,  as  is  so  fre- 
quently done  at  the  present  time — and  even 
the  well  are  adopting  this  wholesome  habit — ■ 

106 


o 

LLl 

UJ 


CURABILITY    AND    TREATMENT 

or  in  a  large  room  with  wide  open  windows 
whatever  the  weather  outside  may  be.  There 
are  also  devices,  such  as  window  tents,  or  es- 
pecially constructed  beds,  whereby  one's  head 
can  be  out-of-doors  while  his  body  is  in  the 
room.  It  used  to  be  thought  that  night-air 
was  injurious,  but  we  know  now  that  it  is  as 
good  as  day-air,  and  sometimes  better,  as  in 
cities,  when  there  is  less  dust  in  the  air  at 
night  on  account  of  the  decreased  traffic. 

(3)  Good  Food.  An  abundance  of  good 
nourishing  food,  properly  arranged  as  to 
quantity,  quality,  and  the  digestive  powers  of 
the  individual,  and,  which  is  most  essential, 
properly  cooked. 

(4)  Tranquillity  and  hopefulness  of  mind, 
for  the  mental  condition  has  much  to  do  with 
the  success  of  the  treatment.  An  unhappy, 
discontented  patient  is  less  likely  to  improve 
in  this  or  any  other  chronic  disease,  as  has 
been  referred  to  in  the  previous  chapter.  The 
writer  once  had  a  patient  who  became  a  Chris- 
tian Scientist,  and  it  produced  such  a  tranquil, 
hopeful  state  of  mind  in  him  that,  whatever 
his  personal  opinion  with  regard  to  this 
pseudo-science  may  be,  it  apparently  in  this 
case  greatly  aided  in  the  successful  issue. 

107 


TUBERCULOSIS 

One  might  add  a  fifth  essential,  so  univer- 
sally is  it  employed  in  the  treatment,  namely, 
the  cold  sponge  or  shower  bath  in  the  morn- 
ing. Of  course  this  is  only  to  be  taken  under 
the  advice  of  the  physician,  for  there  are  cer- 
tain conditions  of.  symptoms  which  would 
render  it  injurious. 

The  whole  treatment  should  be  most  care- 
fully arranged  and  constantly  supervised  by 
the  physician,  who  must  in  the  most  pains- 
taking manner  personally  attend  to  every  de- 
tail,— he  must  provide  for  every  hour  in  the 
day,  as  will  be  further  considered  in  a  sub- 
sequent chapter. 

The  patient  must  be  truthfully  told  of  his 
condition  and  its  dangers,  as  well  as  the  hope- 
ful outlook  from  treatment  if  he  implicitly 
obeys  his  physician.  It  is  a  mistaken  kind- 
ness to  keep  him  in  ignorance  of  his  true  con- 
dition ;  he  is  sure  to  discover  it  later,  and  then 
he  will  lose  confidence  in  his  physician. 
Moreover,  if  he  knows  his  condition,  he  will 
realize  more  fully  the  importance  of  adhering 
rigorously  to  the  treatment. 

From  In-Door  to  Out-Door  Life 

Consumption,  as  has  been  already  said,  is 
io8 


CURABILITY   AND    TREATMENT 

a  disease  of  in-doors,  a  "  house  disease,"  and 
the  in-door  life  must  be  changed  to  an  out- 
door one.  This  is  a  very  radical  change,  and 
it  requires  a  little  time  to  become  accustomed 
to  it. 

One  may  be  apprehensive  of  taking  cold, 
or  fear  that  he  has  not  sufficient  strength 
to  endure  the  exposure,  especially  in  cold 
weather.  When  once,  however,  the  out-door 
habit  is  acquired,  enthusiasm  takes  the  place 
of  fear ;  the  sense  of  well-being  caused  by  the 
stimulating  effect  of  the  constant  exposure  to 
pure  air  is  so  keen,  and  the  evidence  of  the 
beneficial  effects  in  the  improvement  of  all  the 
symptoms,  particularly  the  appetite,  is  so  ap- 
parent, that  one  soon  acquires  a  zest  for  this 
new  mode  of  existence  and  wonders  how  he 
could  have  ever  been  content  with  his  in-door 
life.  "  In  spite  of  rain,  fog  or  snow,"  says 
Dettweiller,  a  pioneer  in  this  form  of  treat- 
ment, "  in  spite  of  a  temperature  below  zero ; 
very  often  without  sun,  the  patient  spends 
from  seven  to  ten  hours  out-of-doors  and 
sometimes  even  eleven  hours.  .  .  ."  After 
a  while  one  acquires  such  a  hunger  for  fresh 
out-door  air  that  he  feels  he  cannot  live  with- 
out it. 

109 


TUBERCULOSIS 

In  sleeping*  out-of-doors,  whether  it  be  in  a 
sleeping  porch,  on  the  piazza,  or  by  use  of  the 
out-door  bed  or  window  tent,  one  can  be  made 
really  comfortable  by  warm  garments  and  bed 
clothes,  a  woolen  hood  for  the  head,  and  a 
soapstone  or  hot  water  bottle  for  the  feet; 
so  that  he  can  sleep  peacefully  even  in  the 
winter  months  of  northern  latitudes.  During 
the  winter  of  1903-1904,  fifty  per  cent,  of  the 
patients  at  the  Adirondack  Cottage  Sanato- 
rium slept  out-of-doors,  not  only  without  in- 
jury, but  with  apparent  benefit,  though  it  was 
one  of  the  coldest  winters  known  there  for 
many  years.  One  surprising  fact  observed 
with  those  taking  the  open-air  treatment  is 
the  inf requency  of  colds, — no  one  has  any  fear 
of  a  draught,  that  bugbear  of  the  in-door 
dweller. 

Rest  in  the  Cure 

Experience  has  shown  that  while  taking  the 
"  cure,"  as  it  is  called,  a  great  deal  of  rest  is 
necessary,  particularly  in  the  beginning.  This 
is  in  accordance  with  the  general  law  of  Na- 
ture, that  an  injured  part  or  diseased  organ 
requires  rest  for  recovery. 

After  the  disease  is  well  on  the  road  to 
recovery  and  the  temperature  is  normal,  then 
carefully  graded  exercise  can  be  begun  and 

no 


CURABILITY  AND   TREATMENT 

gradually  increased  if  no  injurious  effects  fol- 
low. It  has  been  found  that  exercise  under 
these  conditions  increases  the  "  natural  im- 
munity "  of  the  body.  Formerly  the  very 
hazardous  advice  used  to  be  given  to  the  con- 
sumptive to  get  out-of-doors  and  exercise: 
go  West  and  ride  horseback  on  the  plains. 
Sometimes  this  advice  would  be  followed  by 
success,  but  more  times  the  poor  patient  ruined 
his  chances  of  cure  by  so  doing.  Exercise 
must  be  as  carefully  administered  and  regu-; 
lated  as  any  other  part  of  the  treatment.  At 
the  Frimley  Sanatorium  in  England  a  very 
carefully  arranged  series  of  graduated  exer^ 
cises  of  various  kinds  and  degrees  is  employed 
for  suitable  patients,  constantly  supervised  by 
the  physician;  and  the  Frimley  example  has 
been  followed  with  equal  success  in  other  sana- 
toria. The  open-air  treatment  can  be  car- 
ried out  either  in  a  sanatorium,  at  one's  home, 
or  in  a  health  resort  which  is  considered  to 
possess  certain  climatic  excellencies. 

The  Sanatorium  and  Its  Advantages 

Probably  the  "  cure "  can  be  most  effect- 
ively and  successfully  conducted  for  the  ma- 
jority of  consumptives  in  the  modern  sana- 
torium, although  it  must  be  borne  in  mind  that 
:  it  can  be  accomplished  anywhere  if  the  system 

III 


TUBERCULOSIS 

is  rigidly  adhered  to  and  tolerably  pure  air  is 
attainable.  In  the  first  place,  the  sanatorium 
is  built  and  equipped  for  the  express  purpose 
to  which  it  is  devoted,  and  its  physicians  are 
selected  for  their  skill,  experience  and  per- 
sonal fitness  for  this  especial  work.  Being 
constantly  upon  the  ground,  they  exercise  con- 
tinuous supervision  over  the  patients  and  en- 
courage them  in  the  prosecution  of  the  cure. 
For  the  poor  the  State  Sanatorium  offers  bet- 
ter opportunities  than  could  be  obtained  at 
home ;  while  for  the  well-to-do  the  "  paying 
sanatorium,"  so-called,  offers  advantages 
which  only  with  difficulty  and  greater  expense 
could  be  secured  at  home.  Indeed,  in  some 
homes,  the  patient  could  never  be  controlled 
sufficiently  to  successfully  make  the  "  cure.'' 
Again,  by  going  to  the  sanatorium,  all  possi- 
bility of  infecting  other  members  of  the  house 
hold  is  avoided,  for  with  the  best  intentions 
and  the  exercise  of  great  precaution,  infec- 
tion may  occur  through  carelessness  in  dispos- 
ing of  the  sputum.  This  danger  is  greater 
obviously  in  the  crowded  homes  o'f  the  poor. 
The  sanatorium  is,  again,  an  excellent  train- 
ing school  in  the  ways  of  the  open-air  treat- 
ment. Even  if  the  consumptive  is  subse- 
quently treated  at  home,  a  few  weeks  spent  in 

112 


CURABILITY   AND    TREATMENT 

a  well-conducted  sanatorium  is  the  quickest 
and  most  effective  way  to  learn  the  open-air 
method  of  treatment ;  for  the  patient  sees,  day 
after  day,  how  it  is  done,  and  he  quickly  falls 
into  the  routine  and  follows  "  the  lead."  The 
sanatorium  patient  is  made  to  feel  that  he  is 
taking  advantage  of  every  favorable  condition 
in  his  case,  and  all  he  has  to  do  or  think  of  is 
to  follow  out,  from  day  to  day  and  hour  to 
hour,  the  plan  of  life  arranged  for  him, — he 
is  freed  from  all  responsiblity  in  the  manage- 
ment of  his  case,  which  is  a  favorable  attitude 
of  mind  for  recovery. 

As  the  cured  patients  go  forth  from  the 
sanatorium,  they  become  apostles  of  the  fresh 
air  life  and  wholesome  living  in  the  com- 
munities in  which  they  reside.  A  graduate 
of  one  of  the  State  Sanatoria  changed  his 
previous  in-door  occupation  to  that  of  a  milk- 
man for  the  sake  of  the  open-air  life,  and  it 
was  soon  observed  that  the  windows  of  the 
houses  on  his  milk  route  were  more  widely 
and  constantly  open  than  in  other  portions  of 
the  town:  he  had  been  preaching  the  gospel 
of  fresh  air. 

Alleged  Objections  to  the  Sanatorium 

A  frequent  objection  urged  against  the  san- 
113 


TUBERCULOSIS 

atorium  is  that  the  influence  from  the  aggre- 
gation of  so  many  consumptives  is  depressing. 
That  fact,  however,  is  quite  the  reverse,  as  is 
attested  both  by  those  in  charge  of  them  as  well 
as  by  the  inmates.  One  encourages  another, 
and  the  improvement  observed  in  one  patient 
inspires  another,  while  the  physician  in  charge, 
if  he  possesses  the  requisite  qualifications,  en- 
courages and  inspires  all.  Furthermore,  the 
patient's  time  is  so  fully  occupied  in  making 
the  "  cure  "  that  he  has  none  for  depressing 
introspection.  In  a  private  letter  written  to 
the  director  of  a  sanatorium,  a  former  inmate 
thus  gives  his  impressions :  "  A  happier  set 
of  invalids  I  never  saw.  At  my  table  none 
looked  ill,  and  were  as  intelligent  and  refined 
and  jolly  a  crowd  as  I  have  seen  all  summer. 
I  have  visited  in  my  time  many  hospitals, 
asylums  and  homes,  but  none  like  this." 

Another  objection  raised  is  the  danger  of 
reinfection, — of  getting  another  dose  of 
germs,  where  there  are  so  many  consump- 
tives in  such  close  intimacy.  There  is  no 
proof,  however,  that  this  happens.  Every- 
thing in  and  about  the  sanatorium  is  kept 
scrupulously  clean,  and  the  utmost  watchful- 
ness is  observed  in  the  care  of  the  sputum. 

114 


CURABILITY   AND   TREATMENT 

Any  inmate  found  to  be  careless  in  this  re^ 
spect  is  instantly  discharged.  A  director  of 
a  sanatorium  once  told  the  writer  that  a  suc- 
cessful plan  he  pursued  to  prevent  any  care- 
lessness in  spitting  among  the  inmates  was  tc 
tell  each  one  that  he  might  receive  a  new  infec- 
tion and  thus  jeopardize  his  chance  of  recov- 
ery if  anyone  else  should  expectorate  upon  the 
floor  or  ground  or  anywhere  else  where  it 
could  become  dry;  therefore  he  must  sharply 
watch  all  the  others  for  his  own  protection. 
Thus  everybody  was  watching  everybody  else : 
the  law  of  self-preservation  worked  most  ef- 
fectually. 

Examination  of  the  dust  in  various  sana- 
toria and  consumptive  hospitals  has  rarely  re- 
vealed the  presence  of  the  tubercle  bacilli,  and 
then  only  when  some  patient  was  found  to 
have  been  careless  in  the  disposal  of  his  spu- 
tum. As  has  elsewhere  been  mentioned,  the 
sanitary  conditions  in  communities  where 
sanatoria  exist  have  improved,  the  death  rate 
has  fallen,  and  tuberculosis  among  the  in- 
habitants has  diminished. 

No  Medicine  Used  in  the  Sanatorium 

Practically  no  medicine  is  employed  in  the 
115 


TUBERCULOSIS 

modern  treatment  of  tuberculosis,  except  tem- 
porarily in  the  treatment  of  some  symptoms. 
Even  for  cough,  which  is,  perhaps,  one  of  the 
most  frequent  and  constant  symptoms,  medi- 
cines are  rarely  used,  for  experience  has  shown 
that  fresh  air  is  the  most  efficacious  of  all 
remedies.  Furthermore,  the  patient  can  be 
trained  to  suppress  all  unnecessary  coughing 
— that  which  is  accompanied  by  no  expectora- 
tion. Dr.  Dettweiller  used  to  tell  his  pa- 
tients that  they  could  not  come  to  the  public 
dining  table  if  they  coughed,  "  for,"  he  said, 
"  it  is  impolite  to  scratch  one's  head  in  public, 
and  equally  so  to  scratch  one's  throat."  A 
good  method  of  controlling  a  useless  cough 
is,  whenever  the  inclination  to  cough  is  felt, 
to  tightly  close  the  mouth  and  take  several  full, 
slow  breaths  through  the  nose ;  and  repeat 
this  until  the  desire  to  cough  disappears.  In 
the  majority  of  cases,  however,  the  cough  will 
practically  cease  under  the  influences  of  the 
open-air  life. 

Seventy  Per  Cent.  Cured  or  Arrested  in  the  Early 
Stage 

If  consumption  is  discovered  in  its  incipient 
stage  and  the  open-air  treatment  immediately 

ii6 


CURABILITY   AND   TREATMENT 

begun,  a  large  experience  has  proved  that 
60  or  70  per  cent,  or  even  more  can  be  ap- 
parently cured  or  "  arrested."  As,  however, 
the  disease  becomes  more  advanced,  this  per- 
centage rapidly  falls  to  twenty-five  or  twelve 
per  cent.,  until  in  far-advanced  cases  no  cure 
or  arrest  can  be  expected.  How  supremely 
important  it  is,  then,  to  seize  the  moment  when 
the  disease  is  at  its  beginning  to  commence 
treatment,  knowing  that  such  a  large  per 
centage  recovers  at  this  early  stage,  for  it 
cannot  be  too  often  repeated  that  tuberculo- 
sis is  one  of  the  most  curable  of  all  chronic 
diseases.  It  is  infinitely  true  of  tuberculosis, 
as  of  many  other  things,  that  "  there  is  a 
tide  in  the  affairs  of  men,  which  taken  at  the 
flood,  leads  on  to  fortune."  Persistence  in 
the  treatment,  a  rigid  adherence  to  the  plan 
arranged  by  the  skilful  physician  without 
changing  about  from  one  health  resort  to  an- 
other or  one  physician  to  another,  as  some 
do  to  their  grief,  is  the  condition  upon  which 
favorable  results  are  to  be  expected.  Eternal 
vigilance  is  the  price  of  recovery  as  of  liberty. 


";: 


yill.    THE    HOME    TREATMENT    OF 
TUBERCULOSIS 

VEN  with  the  constant  increase  in 
the  number  of  sanatoria  it  is  ap- 
parent that  but  a  small  proportion 
of  consumptives  can  be  accommo- 
dated in  them,  at  least  in  the 
United  States,  even  if  they  all  desired  to 
be.  The  vast  majority  must  be  treated 
at  home  if  treated  at  all.  According  to  Prof. 
Osier  probably  not  more  than  five  per  cent. 
can  take  advantage  of  the  sanatorium  or  of 
climatic  treatment.  Fortunately,  however, 
the  open-air  treatment  can  be  successfully 
carried  out  at  home,  even  in  the  homes  of 
the  poor  in  the  city.  No  consumptive 
need  despair  if  he  is  unable  to  seek  a  new 
climate  or  enter  a  sanatorium.  The  general 
principles  of  the  treatment  are,  of  course,  the 
same,  but  their  application  must  be  modified 
to  suit  the  varying  conditions  of  the  patient 
and  his  surroundings.  Prof.  Osier  thus  tersely 
outlines  the  essentials  of  the  home  treatment: 

Ii8 


HOME   TREATMENT 

"  First,  the  confidence  of  the  patient,  since 
confidence  breeds  hope;  secondly,  a  masterful 
management  on  the  part  of  the  doctor ;  thirdly, 
persistence  .  .  .  ;  fourthly,  sunshine  by 
day,  fresh  air  night  and  day ;  fifthly,  rest  while 
there  is  fever;  sixthly,  breadstuff s  and  milk, 
meat  and  eggs."  The  "masterful  manage- 
ment on  the  part  of  the  doctor  "  is  of  para- 
mount importance,  for  he  must  arrange  the 
plan  to  be  pursued  in  all  its  details. 

It  is  not  by  any  means  only  the  poor  who 
are  treated  at  home.  Others  in  better  circum- 
stances may  desire,  or  be  compelled  from  one 
reason  or  another,  to  do  so.  A  residence  in 
the  country  or  suburbs  of  the  city  is,  of 
course,  to  be  preferred,  for  one  can  obtain 
purer  air  and  more  sunshine,  and  there  are 
fewer  distractions.  If  the  patient  is  unaccus- 
tomed to  discipline,  or  a  child,  the  employment 
of  a  nurse  experienced  in  the  treatment,  at 
least  in  the  beginning,  is  of  great  value.  The 
nurse  can  more  quickly  educate  the  patient  in 
the  details  of  the  cure,  and  if  she  is  agreeable 
and  inspiring,  her  companionship  and  en- 
couragement render  the  routine  of  the  treat- 
ment less  irksome.  It  is  frequently  possible 
and  often  wise  to  send  the  patient,  who  is 

119 


TUBERCULOSIS 

subsequently  to  be  treated  at  home,  to  the 
sanatorium  for  a  brief  period,  as  has  been 
before  mentioned,  in  order  that  the  general 
plan  of  treatment  may  be  more  thoroughly 
and  speedily  learned. 

The  Room  o£  the  Consumptive 

The  room  occupied  by  the  patient  should 
have  a  southern,  or  southwestern  ex- 
posure, not  only  on  account  of  the  sunshine, 
but  because  it  will  be  cooler  in  summer 
and  warmer  in  winter.  It  should  be  large, 
with  abundant  window  space,  and  when  pos- 
sible have  an  open  fireplace.  The  furnish- 
ings should  be  few  and  plain,  without  heavy 
hangings  or  upholstery,  which  collect  and  hold 
dust.  The  floor  should  be  such  that  it  can  be 
easily  washed;  and  everything  in  and  about 
the  room  should  admit  of  easy  and  thorough 
cleaning.  A  rug  or  two  may  be  allowed  on 
the  floor.  The  bed,  unless  one  sleeps  in  the 
open,  should  be  placed  in  such  a  position  as  to 
be  continually  bathed  with  fresh  air.  The  bed 
clothing  should  consist  of  woolen  blankets  or 
of  eider-down  material,  the  latter  having  the 
advantage  of  lightness  as  well  as  warmth. 

120 


;3 


iiMeimm'vy  ....  y"'X"'iiA,-;~'-n-':^iiiMmimii.": 


I 


7 


By  courtesy   Cabinet  Mrg.  to. 

THE    WALSH     WINDOW    TENT. 


HOME    TREATMENT 

For  several  hours  every  morning  the  bed 
clothes  and  mattress  should  be  placed  in  the 
sunlight  and  well  aired.  At  frequent  inter- 
vals the  floor,  walls  and  furniture  should  be 
cleansed  with  soap  and  water  or  wiped  with 
cloths  wet  with  a  solution  of  chlorinated  lime 
or  a  weak  solution  of  corrosive  sublimate.  In 
some  cases,  where  there  is  a  good  deal  of 
coughing  and  expectoration  an  occasional  dis- 
infection with  formaldehyde  gas  is  advised, 
care  being  taken  that  all  small  articles  used 
by  the  patient,  such  as  books,  cards,  baskets, 
etc.,  should  receive  a  thorough  fumigation. 
All  dusting  should  be  done  with  a  damp  cloth. 

The  windows  are  to  be  constantly  open,  ex- 
cept when  dressing  and  undressing.  When 
in  the  room  and  not  in  bed,  the  temperature 
should  be  from  65°  to  6S\ 

A  balcony  or  sleeping  porch  connected  with 
the  bedroom  so  that  the  bed  can  be  rolled  out 
upon  it  through  a  low  window  or  door,  is  a 
very  desirable  addition.  An  adjoining  bath- 
room, which  can  be  warmed,  is  also  desirable 
for  the  cold  bath  in  the  morning. 

One  should  sleep  alone,  and  occupy  the 
room  alone. 

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TUBERCULOSIS 

Care  of  the  Sputum 

The  sputum  (expectoration)  should  be  re- 
ceived in  one  of  the  many  sputum  cups  in  use, 
or  in  a  cuspidor  with  water  or  a  disinfectant 
in  it,  which  should  always  be  kept  covered  and 
the  contents  burned  one  or  more  times  a  day. 
In  coughing  a  piece  of  cloth  or  a  Japanese 
napkin  should  always  be  held  before  the 
mouth  and  subsequently  burned.  Strict  per- 
sonal cleanliness  should  be  observed,  the 
mouth  and  nose  washed  out  several  times  a 
day,  and  the  hands  always  washed  before  eat- 
ing. If  any  sputum  should  accidentally  get 
upon  the  floor,  furniture  or  clothes,  it  should 
immediately  be  wiped  up  with  soap  and  hot 
water,  or  with  a  five  per  cent,  solution  of  car- 
bolic acid.  The  sputum  should  never  be  swal- 
lowed, for  it  may  cause  further  infection. 
One,  of  course,  should  never  spit  anywhere 
except  in  the  proper  receptacle.  If  the  hand- 
kerchief is  used  in  coughing  or  for  the  spu- 
tum, which  is  bad  practice,  it  should  be  washed 
in  boiling  water  before  becoming  dry.  All 
soiled  articles  of  wear  should  be  first  boiled 
before  being  washed.  All  table  utensils 
should  be  reserved  for  the  patient  alone  and 
separately  washed  in  boiling  water. 

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HOME    TREATMENT 

How  the  Day  Should  Be  Spent 

From  seven  to  ten  hours  should  be  spent 
out-of-doors  daily,  winter  and  summer,  and  a 
good  deal  of  this  time  is  to  be  spent  at  rest, 
especially  at  the  beginning  of  the  treatment. 
If  there  is  fever — a  temperature  of  ioo°  or 
over — absolute  rest  is  required.  A  comfort- 
able reclining  chair  is  employed  for  the  open- 
air  rest  "  cure,"  for  the  recumbent  position 
has  been  found  to  be  the  most  comfortable 
and  favorable  one.  In  resting  out-of-doors, 
such  a  place  should  be  selected  as  will  permit 
a  good  circulation  of  air,  and  in  the  sunshine, 
though  it  is  well  to  protect  the  head  from  the 
direct  rays  of  the  sun.  Either  a  piazza,  bal- 
cony or  some  place  in  the  yard  about  the  house 
is  suitable;  or  even  on  the  house  top.  There 
should  be  protection  from  the  wind. 

While  lying  in  the  reclining  chair,  one  can 
occupy  the  time  in  various  simple  ways :  read- 
ing some  unexciting*  literature,  like  Miss 
Austin's  novels,  for  example,  books  of  travel, 
history,  humorous  tales,  like  those  of  Mark 
Twain,  etc. ;  or  he  can  engage  in  some  simple 
handiwork,  such  as  basket  weaving,  wood 
carving,  paper  cutting,  etc.,  or  play  an  unex- 
citing game  with  a  friend,  though  much  talk- 

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TUBERCULOSIS 

ing  and  visiting  is  generally  a  useless  expendi- 
ture of  strength.  If  the  patient  is  fortunate 
enough  to  have  a  pleasing  stretch  of  land- 
scape before  him  he  will  often  be  content  to 
enjoy  the  view  and  so  let  the  hours  go  by,  as 
the  passenger  on  the  ocean  steamship  spends 
hours  and  days  sitting  idly  in  his  chair  simply 
watching  the  ever-changing  scenery  of  sky 
and  sea.  A  patient  who  was  taking  the  open- 
air  "  cure ''  once  remarked  to  the  writer  that 
it  took  him  so  much  time  to  do  nothing  that 
he  had  no  time  to  write  a  letter.  In  the  homes 
of  the  city  poor,  the  house  top,  the  back  yard, 
a  piazza,  when  there  is  one,  an  improvised 
balcony,  or  even  the  fire-escape,  will  serve  for 
the  out-door  life. 

Day  Camps  and  "Classes'* 

The  day  camp  is  an  admirable  and  inex- 
pensive method  of  affording  out-door  life  dur- 
ing the  day  to  those  who  must  remain  at  home, 
in  poor  quarters,  or  crowded  portions  of  the 
city,  or  while  waiting  for  entrance  into  a  sana- 
torium. For  its  location  an  open  space  is  se- 
lected in  the  environs  of  the  city,  where  there 
is  a  free  circulation  of  air,  and,  if  possible,  the 
shade  of  trees.  The  equipment  is  simple, — 
one  or  two  rude  buildings   for  the  kitchen, 

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HOME    TREATMENT 

physicians'  examining  office,  etc.,  and  a  large 
dining  tent  or  other  structure.  The  consump- 
tive comes  to  the  camp  in  the  morning  and 
spends  the  day  in  his  recHning  chair  under 
the  trees.  He  is  under  the  supervision  of 
the  attending  physician,  and  receives  several 
nourishing  meals  during  the  day.  He  returns 
to  his  home  at  night,  to  come  again  the  next 
morning,  thus  spending  each  day,  for  weeks 
or  months,  out-of-doors.  Excellent  results 
have  been  obtained  from  this  effective  method 
of  out-door  treatment,  and  experience  has 
shown  that  it  can  be  continued  throughout 
the  year. 

The  tuberculosis  class  has  become  a  popu- 
lar and  very  useful  method  of  treating  small 
numbers  of  poor  patients  in  their  homes  in  a 
large  city.  It  consists  of  a  small  group — a 
class — of  consumptives,  who  are  under  the 
strict  supervision  of  the  physician  of  the  class, 
whom  they  meet  regularly  once  a  week,  and 
who  discusses  with  them  the  details  of  the  past 
week  and  advises  them  as  to  their  future 
course.  Each  patient  keeps  a  diary  of  his 
condition,  the  food  and  milk  taken,  exercise, 
the  number  of  hours  spent  out-of-doors,  his 
temperature  and  pulse,  general  condition,  etc. 

In  addition  to  the  weekly  class  meetings,  a 
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TUBERCULOSIS 

nurse  visits  the  patients  at  their  homes  and 
sees  that  they  carry  out  the  treatment.  Such 
classes  are  often  supported  by  churches  and 
are  given  the  name  of  the  church  which  has 
charge  of  them,  as  the  "  Emmanuel  Church 
Tuberculosis  Class,"  which  was  the  original 
class  of  this  kind,  and  was  the  happy  concep- 
tion of  Dr.  Pratt  of  Boston.  The  patients  are 
aided  pecuniarily  when  necessary  by  funds 
contributed  by  the  church.  Tents,  reclining 
chairs,  sputum  cups  and  paper  handkerchiefs, 
and,  in  special  cases,  food  are  furnished.  After 
recovery  the  patients  are  often  aided  in  se- 
curing proper  employment. 

By  means  of  this  admirable  method  of  home 
treatment,  many  lives  have  been  saved  and 
returned  to  work.  Many  cities  and  other 
countries  have  taken  up  this  system.  The  edu- 
cational value  of  the  class  system  is  great: 
not  only  the  patients,  but  their  families  and 
friends  are  taught  by  observation  and  ex- 
perience the  beneficial  effect  of  fresh  air  and 
proper  hygienic  living,  both  in  the  recovery 
and  maintenance  of  health.  While  under 
treatment  the  patients  are  required  to  devote 
their  entire  time  to  it. 


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HOME   TREATMENT 

Sleeping   Arrangements 

The  night  should  be  passed  either  out-of- 
doors  or  in  a  large  room  with  wide  open  win- 
dows; in  the  former  case  some  of  the  many 
arrangements  for  out-door  sleeping  can  be  em- 
ployed. The  patient  should  go  to  bed  early 
and  accustom  himself  to  sleep  from  nine  to 
ten  hours.  Indeed,  life  in  the  open  air,  as 
everyone  has  experienced,  conduces  to  long, 
sound  sleep.  As  a  further  preparation  for 
sleep,  the  evening  hours  can  be  passed  in  a 
quiet,  restful  manner,  so  that 

"The  cares,  that  infest  the   day. 
Shall  fold  their  tents,  like  the  Arabs, 
And  as  silently  steal  away." 

In  sleeping  out-of-doors  during  the  winter, 
it  is  important  that  enough  bed  and  body 
clothing  should  be  used  to  make  one  com- 
fortable,— blankets,  eider-down  quilts,  woolen 
pajamas,  or  a  sleeping  bag  of  some  heavy 
woolen  material,  a  hood  or  helmet  for  the 
head,  and  woolen  socks,  will  accomplish  this, 
and  thus  clad  like  an  Arctic  traveler,  one  can 
brave  the  severity  of  almost  any  winter's 
night  and  be  comfortable.  Those  who  are  ac- 
customed to  out-door  sleeping  speak  with  en- 

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TUBERCULOSIS 

thusiasm   of   the   refreshing   sensation   when 
they  awake  in  the  morning. 

Exercise 

After  a  little  time,  when  the  treatment  is 
well  established  and  there  is  no  fever,  some 
exercise  may  be  taken,  but  only  upon  the  ad- 
vice of  the  physician.  For  the  majority  of 
patients,  walking  is  probably  the  best  and 
safest  exercise,  but  whatever  it  is,  it  should 
never  be  violent  or  excessive.  If  it  is  walking, 
it  should  be  leisurely  and  not  fast  enough  to 
cause  coughing,  shortness  of  breath  or  fatigue. 
All  exercises  which  require  considerable  ex- 
ertion and  rapidity  of  motion,  like  horseback 
riding,  tennis,  bicycle  riding,  and  the  like,  are 
unsafe,  and  many  a  consumptive  has  gone  to 
his  destruction  by  indulging  in  them.  Games 
requiring  little  exertion,  like  croquet,  are  al- 
lowable. No  exercise  should  be  taken  before 
or  directly  after  meals.  A  good  general  rule 
is  to  take  only  so  much  exercise  as  does  not 
interfere  with  the  favorable  progress  of  the 
disease  towards  recovery.  "  More  consump- 
tives kill  themselves,"  says  a  German  author- 
ity, "  by  doing  too  much  than  in  any  other 
way."     Lung  gymnastics  and  deep  breatliing 

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exercises  for  expanding  the  chest  are  some- 
times advised,  but  they  should  never  be  taken 
except  with  the  sanction  and  under  the  super- 
vision of  the  physician.  Many,  good  authori- 
ties are  opposed  to  all  such  exercises  and  con- 
sider them  harmful:  the  diseased  lung,  they 
contend,  like  other  diseased  portions  of  the 
body,  heals  sooner  by  rest  or  the  avoidance  of 
all  unnecessary  exertion.  As  recovery  pro- 
gresses, both  greater  physical  and  mental  ef- 
fort may  be  allowed,  for  it  must  be  remem- 
bered that  the  habits  of  confirmed  invalidism, 
so  fatal  to  future  usefulness,  may  be  formed 
while  the  "  cure  "  is  taking  place.  In  certain 
sanatoria  the  inmates  who  are  on  the  way  to 
recovery  are  gradually  accustomed  to  do  a 
little  more  work,  and  a  little  and  a  little  more 
severe,  until  by  the  time  they  have  recovered 
they  can  do  more  or  less  of  an  ordinary  day's 
work. 

Food 

Someone  has  said  that  "  a  consumptive  who 
does  not  eat  is  a  consumptive  lost,"  and  it  is 
quite  obviously  true.  No  perfection  of  the 
open-air  life  will  avail  without  good  nutrition. 
Good  and  nutritious  food  in  abundance,  and 

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TUBERCULOSIS 

good  digestion,  are  vital  to  the  success  of  the 
open-air  treatment.  The  test  as  to  whether  or 
not  a  patient  is  being  properly  nourished  is 
a  steady  gain  in  weight  until  the  normal  is 
reached.  If  the  digestion  is  good,  a  mixed 
diet  consisting  of  proper  proportions  of  the 
proteids,  fats  and  carbohydrates,  such  as  meat, 
vegetables,  bread  and  butter,  milk,  eggs,  va- 
rious fats,  fish,  fruit,  soups,  etc.,  taken  at  the 
usual  times  may  be  sufficient.  If  the  weight 
and  strength  are  deficient,  probably  the  three 
meals  will  have  to  be  supplemented  by  be- 
tween-meal  lunches,  consisting  of  milk,  raw 
eggs,  bread  and  butter,  cocoa,  chocolate,  soup, 
etc. 

The  food  should  be  varied,  well  cooked  and 
served  in  a  tempting  manner.  The  appetite 
is  not  always  a  safe  guide.  The  main  thing 
is  to  eat  and  digest  the  proper  amount  of  food, 
for  the  appetite,  like  rumor,  "  grows  by  what 
it  feeds  on."  Generally,  however,  the  out- 
door life  brings  a  keen  desire  for  food.  Milk 
is  a  most  important  article  in  the  consump- 
tive's dietary,  and  most  persons  can  take  it, 
although  one  now  and  then  thinks  he  cannot 
It  should  be  taken  slowly  or  sipped.  Some- 
times as  much  as  three  pints  or  more  are  taken 

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daily  in  addition  to  the  regular  meals,  particu- 
larly if  the  patient  is  below  weight.  Next  in 
importance  to  milk  are  eggs,  preferably  raw. 
Fats  in  liberal  quantities  are  generally  essen- 
tial for  the  tuberculous  patients  and  are  fur- 
nished in  the  form  of  milk,  cream,  butter, 
bacon  and  olive  oil. 

The  kind  and  quantity  of  food,  and  the 
hours  of  taking  it,  must  be  carefully  arranged 
by  the  physician,  and  it  is  often  well  for  the 
patient  to  keep  an  exact  record  of  his  daily 
food  as  well  as  the  number  of  hours  he  spends 
out-of-doors  and  the  exercise  he  takes.  An 
English  authority  declares  that  the  important 
items  of  a  consumptive's  food  should  be  or- 
dered in  definite  amounts  and  weighed  out 
each  day  until  by  practice  one  has  learned  to 
guess  at  the  amounts  with  sufficient  accuracy. 
Simply  to  tell  the  patient  to  "  feed  up,"  as  is 
frequently  done,  is  a  very  inadequate  concep- 
tion of  this  most  vital  part  of  the  treatment. 
If  the  question  of  nutrition  is  dismissed  in  this 
off-hand  manner,  it  will  sometimes  be  discov- 
ered, too  late,  that  the  patient  is  "  feeding 
down  "  to  his  destruction.  One  should  rest 
an  hour  before  the  principal  meals. 

It  is  not,  of  course,  possible  in  all  or  many 
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TUBERCULOSIS. 

cases,  to  provide  elaborate  menus,  or  is  it 
necessary,  but  in  almost  every  household 
someone  can  be  found,  or  trained,  to  prepare 
the  essentials  of  a  proper  consumptive  diet. 
(With  the  study  of  a  good  cook  book,  or  a 
treatise  on  dietetics,  or  a  few  lessons  in  a 
cooking  school,  one  can  learn  to  do  this. 

Someone  has  called  eating  an  act  of  wor- 
ship, and  at  this  shrine  must  the  consumptive 
worship  with  his  whole  heart  if  he  would  ob- 
tain salvation  from  his  disease. 

Alcohol  in  any  form  is  very  rarely  employed 
in  the  treatment  at  the  present  time,  and 
should  never  be  used  unless  prescribed  by  the 
physician.    The  best  drink  is  pure  water. 

The  Hardening  Process  and  the  Cold  Bath 

The  open-air  treatment  may  be  regarded  as 
a  kind  of  "  hardening "  process,  intended  to 
increase  one's  general  resistance  to  the  disease. 
The  contmuous  out-door  life  in  itself,  in  all 
kinds  of  weather,  and  varying  temperatures, 
particularly  during  the  winter  season  of 
northern  latitudes,  is  perhaps  the  most  impor- 
tant part  of  this  process. 

The  application  of  cold  water  to  the  skin, 
the    cold    bath,    further    contributes    to    this 

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hardening  process.  By  its  use  the  action  of 
the  skin  is  increased,  the  susceptibility  to  tem- 
perature and  cHmatic  changes  lessened,  the 
appetite  improved,  and  the  whole  system  stim- 
ulated. With  a  delicate  person,  one  may  be- 
gin with  dry  rubbing  night  and  morning,  either 
simply  with  a  coarse  tovv^el,  a  rough  hand 
glove,  or  by  wrapping  the  patient  in  a  coarse 
sheet  and  rubbing  him  over  the  sheet.  Later, 
moist  rubbings  can  be  substituted  by  means 
of  a  wet  coarse  cloth,  or  by  enveloping  him  in 
a  wet  sheet,  beginning  with  a  temperature  of 
90°  and  gradually  reducing  it  to  70°  or  60°. 
With  many  patients,  perhaps  the  majority,  in 
the  early  stages  of  the  disease,  a  cool  or  cold 
sponge  or  shower  bath  can  be  begun  at  once. 
If,  however,  there  is  failure  of  reaction,  indi- 
cated by  chilliness,  and  a  blueness  of  the  skin, 
the  bath  must  be  modified  or  omitted.  The 
test  of  the  good  effects  of  the  cold  bath  is  a 
quick  reaction,  a  feeling  of  warmth  and  well- 
being,  and  an  improvement  of  appetite,  diges- 
tion and  circulation. 

Dr.  Minor  of  Asheville,  North  Carolina, 
gives  an  easy  and  simple  method  of  taking 
a  cold  bath  by  the  use  of  no  more  complicated 
apparatus  than  a  tin  tub,  a  bath  thermometer, 

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TUBERCULOSIS 

a  big*  sponge,  salt  and  a  rough  Turkish  towel. 
His  method  of  procedure  is  as  follows:  Gifie 
or  two  buckets  of  water  and  a  handful  of 
sea  salt  are  placed  in  the  tub,  the  water,  on 
beginning  the  bath,  being  at  a  temperature  of 
loo°  F.,  which  is  reduced  a  degree  every  day 
until  70°  to  55°  is  reached.  The  patient  sat- 
urates the  large  sponge  with  water,  stands 
erect,  holds  it  over  his  shoulders  and  neck,  and 
squeezes  out  the  whole  volume  at  once,  in  a 
shower  down  his  back  and  neck,  thus  produc- 
ing a  douche.  This  is  repeated  rapidly  over 
all  parts  of  the  body  for  about  half  a  minute ; 
then  the  patient  jumps  out,  rubs  off  briskly 
with  the  rough  Turkish  towel  and  at  once 
dresses.  Instead  of  the  sponge,  a  pitcher  of 
water  can  be  used. 

There  are  many  other  methods  of  applying 
water  for  its  stimulating  and  hardening*  ef- 
fect, such  as  the  cold  friction  by  means  of  a 
wet  sheet,  a  wet  pack,  the  douche  and  shower 
baths,  but  the  one  described  above  is  the  most 
simple  and  is  within  the  reach  of  anyone. 

Clothing 

There  is  no  special  kind  of  clothing  for  the 
tuberculous    individual    different    from    that 

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worn  by  any  well  person.  He  should  be 
clothed  so  as  to  be  comfortable,  and  no  more 
than  will  accomplish  this.  Unduly  heavy 
clothing  has  a  tendency  to  relax  the  skin  and 
produce  profuse  perspiration  upon  any  slight 
exertion,  rendering  the  body  more  sensitive  to 
changes  of  temperatures,  and  more  liable  to 
catch  cold.  The  clothing  should  be  equally 
distributed  over  the  body,  and  no  greater 
thickness,  such  as  chest  protectors,  or  extra 
jackets,  should  be  worn  over  the  chest  than 
elsewhere.  The  under  garments  should  be 
woolen  or  merino  which  contains  a  certain 
proportion  of  cotton,  and  only  of  such  weight 
as  will  keep  one  comfortable.  They  should 
be  loose  enough  to  permit  a  layer  of  air  be- 
neath them  that  an  equable  temperature  may 
be  maintained.  "  Inside  our  dress,"  says 
Pettenkoffer,  "  we  should  carry  the  air  of  the 
South  wherever  we  may  be.  We  live  in  our 
dress  like  an  unclothed  tribe  in  a  Paradisian 
country  where  the  air  is  constantly  calm  and 
the  temperature  from  75°  to  94°."  The  un- 
der-clothing worn  during  the  day  should  be 
removed  at  night  and  thoroughly  aired. 
Women  should  wear  short  skirts :  trailing  ones 
are  a  menace  both  to  themselves  and  those 

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TUBERCULOSIS 

about  them  from  the  dirt  and  dust  they  col- 
lect. 

Precautions  and  Mode  of  Life  After  Recovery 

As  pulmonary  tuberculosis  is  a  disease,  for 
the  most  part  of  in-door  life,  the  out-door 
life  is  one  of  the  principal  factors,  as  we  have 
seen,  in  the  accomplishment  of  the  cure. 
After  recovery,  therefore,  the  out-door  life, 
so  far  as  possible,  should  be  continued.  In- 
deed, very  much  the  same  general  plan  of  life 
pursued  during  the  treatment  is  to  be  the 
guide  for  one's  subsequent  mode  of  living. 
Sometimes  it  will  be  possible  for  one  to  adopt 
some  out-door  occupation,  or,  if  the  in-door 
life  must  be  resumed,  one  can  embrace  every 
opportunity  to  spend  a  certain  amount  of  time 
daily  out-of-doors:  for  example,  by  walking 
to  and  fro  from  one's  place  of  business,  an 
evening  walk,  sleeping  out-of-doors,  and 
spending  the  holidays  in  the  open  air. 

The  "  night  camp "  is  a  recent  develop- 
ment, by  means  of  which  the  city  worker  who 
has  recovered  from  tuberculosis  can  go  out 
into  the  suburbs  and  sleep  under  fresh-air 
conditions  impossible  for  him  to  obtain  in  the 
city.     Upon  a  suitable  open  space,  specially 

136 


HOME   TREATMENT 

designed  buildings  are  erected,  where  one  can 
sleep  with  an  abundance  of  fresh  air  or  even 
out-of-doors,  and  after  a  good  breakfast  in 
the  morning  return  to  the  city  for  his  day's 
work.  By  this  means  it  is  hoped  that  many 
a  relapse  will  be  averted. 

In  some  instances  an  in-door  occupation 
can,  to  a  certain  extent,  be  converted  into  an 
out-door  one  by  working  with  open  windows, 
and  securing  a  free  circulation  of  air. 

Especial  precautions  should  be  taken  for 
several  years  after  recovery,  for  if  a  relapse 
occurs  it  is  more  likely  to  happen  within  this 
period ;  indeed,  the  cure  cannot  be  considered 
absolute  until  at  least  two  or  three  years  have 
elapsed.  Excessive  physical  and  mental  ex- 
ertion is  to  be  avoided  as  well  as  all  excesses. 
If  there  are  any  indications  of  retrogression 
from  the  normal  standard  of  health,  such  as 
loss  of  weight,  strength,  appetite,  etc.,  the  tem- 
perature should  be  taken  for  a  number  of  days, 
and  if  any  fever  is  present,  treatment  must  at 
once  be  resumed.  A  cold,  the  "  grippe,"  or 
any  respiratory  disease  must  receive  imme- 
diate and  careful  attention.  Sufficient  rest, 
pure  air,  good  food,  the  avoidance  of  over- 
exertion,   and    the    general    conservation    of 


TUBERCULOSIS 

energy  are  cardinal  principles  of  living  ever 
to  be  borne  in  mind  by  the  cured  consumptive. 
The  objection  may  naturally  be  urged  that 
to  treat  a  case  of  tuberculosis  v^^ith  all  the  at- 
tention and  detail  outlined  above  would  re- 
quire the  command  of  considerable  pecuniary 
means  as  well  as  one's  entire  time  for  an  ex- 
tended period,  and  would,  therefore,  be  be- 
yond the  reach  of  many  consumptives.  True, 
the  ideal  plan  of  treatment  does  require  both 
time  and  money :  it  could  not  be  otherwise  with 
a  disease  whose  treatment  depends  upon  the 
prolonged  influences  of  hygienic  measures  to 
restore  the  lost  power  of  resistance.  From 
the  ideal  plan,  however,  modifications  can  be 
made  according  to  the  exigencies  and  limita- 
tions of  the  individual  case;  and  it  is  better 
to  have  a  standard  and  to  come  as  near  to  it 
as  one  can,  bearing  always  clearly  in  mind  the 
great  general  principles  of  the  treatment. 

A  Suggestive  Daily  Routine 

The  physician,  after  a  painstaking  examina- 
tion of  the  patient  and  a  careful  considera- 
tion of  his  individual  condition,  alike  as  to  his 
disease,  his  environment,  and  social  and  pe- 
cuniary state,  prepares  a  plan  of  treatment  in 

138 


HOME    TREATMENT 

detail,  and  thenceforth  exercises  a  constant 
and  close  supervision  over  him.  Nothing  is 
left  to  chance  or  the  caprice  of  the  patient. 
The  physician  must  command  and  the  patient 
must  co-operate  v^ith  him  and  obey.  The  fol- 
lowing is  a  suggestive  daily  routine,  such  as 
the  physician  prepares,  for  an  average  patient 
in  the  early  stage  of  the  disease,  whose  general 
physical  condition  is  good  and  who  has  no 
fever. 

7  or  7.30  A.  M.  Arise  and  take  a  cool  or 
cold  sponge  bath  in  a  warm  room,  and  then 
dress.  On  awakening  or  while  dressing,  a 
glass  of  hot  milk,  bouillon,  a  cup  of  weak 
coffee  with  cream,  or  cocoa  may  be  taken  as 
directed. 

7.30  or  8  A.  M.  Breakfast,  which  is  a 
substantial  one,  consisting,  for  example,  of 
weak  tea,  coffee  or  cocoa,  a  cereal  with  cream 
and  sugar,  some  meat,  or  bacon  with  eggs, 
bread  and  butter,  and  milk. 

8  or  9  to  II  A.  M.  Rest  in  the  reclining 
chair  and  whatever  exercise  is  ordered. 

II  A.  M.  A  glass  of  milk,  a  raw  egg  or  a 
light  lunch  of  some  kind  if  ordered. 

11  to  12  M.     Rest  or  exercise  as  ordered. 

12  to  I  P.  M.     Rest  in  the  reclining  chair 

139 


TUBERCULOSIS' 

out-of-doors,   or    in    one's    room    with    open 
windows. 

1  to  2  P.  M.  Dinner  of  a  liberal  mixed 
diet,  consisting  of  soup,  meat,  vegetables, 
bread  and  butter,  milk  and  some  simple  des- 
sert, and  fruit. 

2  to  2.30  P.  M.     Rest. 

2.30  to  4  or  5  P.  M.  Rest  in  the  reclining 
chair  or  a  walk  if  ordered,  shorter  than  in 
the  forenoon. 

4.30  or  5  P.  M.  A  light  lunch  of  milk,  etc., 
as  in  the  forenoon. 

5  to  6  or  6.30  P.  M.     Rest  as  before  dinner. 

6  or  6.30  P.  M.  Supper,  which  should  be 
a  substantial  one. 

7  or  7.30  to  9  or  9.30  P.  M.  In  a  well- 
ventilated  room,  or  upon  the  piazza  when  the 
weather  permits. 

9  to  10  P.  M.  Retire,  and  just  before  re- 
tiring a  glass  of  milk. 

The  lunches  may  be  omitted  if  the  nutrition 
and  weight  are  satisfactory. 

Of  course  the  above  day's  plan  is  subject 
to  change  as  indications  arise,  according  to  the 
discretion  of  the  physician. 

The  weight  is  to  be  taken  every  week. 

Thus,  it  will  be  seen  that  to  get  well  of 
140 


HOME    TREATMENT 

tuberculosis  requires  the  persistent  and  con- 
tinued adherence  to  a  strict  daily  routine,  but 
the  habit  is  soon  established,  and  one  is  sus- 
tained by  the  reasonable  expectation  of  a  suc- 
cessful result,  if  he  perseveres  in  the  treat- 
ment. 
Some  Aphorisms  for  the  Tuberculosis  Patient 

1.  "  The  labor  which  best  repays  a  sick  man 
is  to  get  well." 

2.  "Desire  but  one  thing"  (to  get  well) 
"  and  that  with  all  the  heart." 

3.  "Whatever  thou  takest  in  hand  remem- 
ber the  end,  and  thou  shalt  never  do  amiss." 

4.  "  Whatever  is  worth  doing  is  worth  doing 
well." 

5.  "  Where  sunlight  enters  not  there  the 
physician  goes." 

6.  "  He  that  taketh  heed  shall  prolong  his 
life." 

7.  "  Life  is  not  to  live,  but  to  be  well." 

8.  "  He  who  has  health  has  hope,  and  he 
who  has  hope  has  everything." 

9.  "  Be  intent  only  on  that  which  thou  art 
now  doing  and  on  the  instrument  by  which 
thou  doest  it." 

10.  "  Your  most  important  duty  is  to  get 
well.     Let  all  other  duties  be  secondary." 

141 


IX.     TUBERCULOSIS   AND    CLIMATE 

CUBERCULOSIS  is  no  respecter 
of  climate,  but  "  extends  over 
every  part  of  the  habitable  globe." 
"  It  is,"  as  has  been  said  by  Prof. 
Hirsch,  "  emphatically  a  disease  of 
all  times,  all  countries,  and  all  races.  No  cli- 
mate, no  latitude,  no  occupation,  no  combina- 
tion of  favoring  circumstances  forms  an 
infallible  safeguard  against  its  onset."  Cold 
or  dampness  does  not  produce  it,  or  warmth 
prevent  it,  for  neither  one  nor  the  other  de- 
stroys the  tubercle  bacilli,  and  when  a  favora- 
ble soil  in  the  individual  exists  and  he  is 
exposed  to  the  bacilli  a  sufficiently  long  time, 
he  will  contract  the  disease  in  whatever  cli- 
mate he  may  be. 

One  would,  however,  naturally  suppose  that 
in  those  regions  where  the  climate  is  "  favor- 
able," as  we  say,  permitting  a  constant  out- 
door life,  the  opportunities  for  being  brought 
in  contact  with  the  germs  would  be  less,  and 
the  conditions  for  resisting  them  more  favor- 
able.    Such  undoubtedly  would  be  the  case 

142 


TUBERCULOSIS    AND    CLIMATE 

and,  indeed,  has  been  found  to  be  so  provided 
other  conditions,  such  as  sufficient  and  whole- 
some food,  pure  air  at  night  as  well  as  day, 
and,  in  general,  good  hygiene  and  sanitary 
conditions,  prevailed.  For  example,  a  person 
living  a  wholesome  life  on  a  ranch  in  South- 
ern California,  Colorado  or  New  Mexico, 
where  abundant  sunshine,  pure  air,  dryness 
of  atmosphere,  and  but  little  rain  were  the 
climatic  characteristics  throughout  the  year, 
would  probably  be  less  likely  to  contract  tu- 
berculosis than  upon  a  New  England  farm 
where  the  weather  conditions  in  the  winter 
and  spring  were  distinguished  by  much  cold 
moisture,  frequent  storms  of  snow  or  rain, 
and  much  cloudiness,  compelling  one  to  pass 
a  very  considerable  amount  of  time  in-doors. 
And  the  same  argument  holds  good  in  the 
treatment  of  tuberculosis,  other  things  being 
equal,  as  we  shall  later  discuss.  "If  sunlight 
is  good  at  all,"  says  Dr.  Knight,  "  why  isn't 
it  better  to  have  twenty-five  or  more  days  of 
it  per  month  than  to  have  ten  or  twelve  or 
less?" 

Unhygienic  Conditions  in  Cities 

In  the  cities,  however,  unfavorable  hygienic 
143 


TUBERCULOSIS 

conditions,  particularly  overcrowding,  poor 
nutrition  and  impure  air  at  night  exercise 
their  baneful  influences  just  as  surely  in  the 
favorable  as  the  unfavorable  climates.  For 
example,  in  the  South  and  in  the  tropics 
where  the  climate  favors  a  constant  out-door 
life,  tuberculosis  is  one  of  the  most  frequent 
diseases  in  cities  situated  in  these  regions,  as 
in  Havana,  Rio  Janeiro,  Alexandria,  Egypt, 
etc.  In  the  high  altitudes,  which  were  sup- 
posed to  be  particularly  free  from  tuberculosis, 
as  well  as  favorable  for  its  cure,  densely  popu- 
lated cities,  like  Mexico  City,  Bogota,  Quito 
in  South  America,  etc.,  again  show  a  large 
mortality  from  tuberculosis.  In  Bogota  the 
persons  affected  by  tuberculosis  were  found 
to  belong  to  the  lowest  and  poorest  class  of 
the  population  who  lived  in  most  unfavorable 
hygienic  conditions.  A  good  climate  will  not 
counteract  bad  living  conditions. 

So  long  as  the  Indians  led  a  nomadic  life 
on  the  Western  plains,  they  rarely  suffered 
from  tuberculosis,  but  when  they  changed 
this  free  life  for  a  confined  one  in  barracks, 
and  lived  in  closely  settled  communities,  they 
readily  contracted  the  disease  and  suffered 
severely   from   it.     In   a   community   of  400 

144 


TUBERCULOSIS    AND    CLIMATE 

Apache  Indians  taken  from  a  free  nomadic 
life  in  Arizona  and  New  Mexico  and  trans- 
ferred to  Alabama,  where  they  occupied  log 
cabins,  the  deaths  from  tuberculosis  in  five 
years  was  78,  or  43J  per  cent,  of  the  total 
number.     *' In  his  original  life,"  says   Com- 
missioner  Leupp,   "the   Indian  had  no  per- 
manent home,  and  his  pursuits  were  all  such 
as  kept  him  out-of-doors   and  hardened   his 
body.     When   his  tepee   became   surrounded 
with  filth,  he  moved  it  to  a  fresh  spot.     He 
wore  little   clothing— in  some  places   almost 
none.     Exposure    to   the   open   sunshine,   a 
hardy  meat  diet,  and  a  scattered  and  ever- 
moving  population  were  pretty  sure  defense 
against  germs.     Times  have  changed.     The 
Indian   can   no   longer   roam   everywhere   at 
will.     He  overburdens  his  body  with  modern 
clothing.     He  has  been  taught  to  live  in  a 
cabin,  in  which  he  nails  down  the  few  win- 
dows, caulks  the  cracks  and  sets  up  a  stove 
which  he  heats  red-hot.     In  the  one  or  two 
rooms  of  this  dwelling  he  eats,  sleeps,  rears 
his    family,    entertains    his    large    circle    of 
friends— expectorates,  sickens  and  dies.     All 
the  conditions  are  perfect  for  the  spread  of 
tuberculosis.    In  due  course  of  time  his  com- 

145 


TUBERCULOSIS 

munity  becomes  a  nest  of  infection  for  the 
larger  white  community  that  is  fast  growing 
up  about  him."  In  the  islands  of  the  West 
Indies,  tuberculosis  is  very  prevalent  among 
the  colored  population,  though  they  live  an 
out-of-door  life  under  sunny  skies.  This  is 
largely  due,  it  is  believed,  to  the  habit  they 
have  of  shutting  themselves  up  tightly  at 
night  in  their  crowded  cabins  from  an  unrea- 
soning fear  of  night  air. 

Among  the  Scandinavians  in  the  country 
regions  of  Minnesota  tuberculosis  is  said  to 
be  more  prevalent  than  in  the  cities  of  that 
state,  and  the  cause  is  attributed  to  the  fact 
of  their  in-door  life  without  proper  ventila- 
tion during  their  long,  cold  winter.  The  cold, 
dry  climate  of  Minnesota  is  a  wholesome  one, 
and  was  regarded  as  favorable  for  the  cure 
of  tuberculosis,  but  it  is  powerless  against 
in-door  life  and  impure  air. 

Consumption  Rare  in  Out-Door  Life 

Any  favorable  climate  must  be  utilized  to 
be  beneficial,  and  an  unfavorable  one,  if 
rightly  made  use  of,  by  breathing  fresh  air 
day  and  night,  is  of  far  more  value  in  main- 
taining one's  health  or  in  the  recovery  from 

146 


TUBERCULOSIS   AND    CLIMATE 

tuberculosis.  We  see,  then,  that  it  is  not  alone 
the  climate  of  a  place  which  is  conducive  to 
tuberculosis  or  its  cure,  but  the  way  people 
live  in  that  climate. 

"  There  is  a  vast  mass  of  evidence,"  says 
Lindsay,  "  which  conclusively  proves  that  con- 
sumption is  comparatively  rare  among  those 
who  follow  an  out-door  life  under  normal  and 
healthy  conditions;  that  it  is  comparatively 
common  among  those  who  live  habitually  in- 
doors, and  that  it  attains  its  maximum  inci- 
dence among  those  whose  occupation  involves 
prolonged  confinement  in  a  vitiated  atmos- 
phere." 

In  the  treatment  of  tuberculosis,  climate 
has  played  an  important  role,  more  so  in  the 
past  perhaps  than  at  the  present  time.  (Experi- 
ence in  sanatoria,  which  have  been  established 
in  all  kinds  of  climates,  as  well  as  experience 
in  the  home  treatment,  has  taught  us  that  any 
climate  where  the  air  is  pure  and  free  from 
dust,  and  there  is  protection  from  high  winds, 
is  favorable  for  the  treatment  of  the  disease. 
Dettweiller,  who  established  the  famous  sana- 
torium at  Falkenstein  in  Germany,  which  pos- 
sesses a  climate  much  like  that  of  New  Eng- 
land, once  told  the  writer  that  he  could  cure 

147 


TUBERCULOSIS 

tuberculosis  in  any  climate,  and  surely  his 
success  in  his  own  sanatorium  has  proved  his 
statement. 

Climate  Only  One  Factor 

It  is  the  combination  and  painstaking  appli- 
cation of  all  the  several  units  of  the  open-air 
treatment  which  bring  success,  and  not  climate 
alone,  upon  which  so  great  reliance  was  for- 
merly placed.  Careful  medical  supervision, 
rest,  proper  and  abundant  nourishing  food, 
mental  repose,  and,  in  brief,  the  most  careful 
regulation  of  the  patient's  life,  are  as  essential 
as  climate.  "Is  there  not,  then,"  one  natu- 
rally asks,  "  any  value  in  what  are  called  fav- 
orable climates  for  the  consumptive,  such  as 
those  of  Colorado,  Southern  California,  the 
southern  pine  belt,  Asheville,  the  Adiron- 
dacks,  and  many  others  at  home  and  abroad  ?  " 
Long  experience  has  shown  that  "  favorable  " 
climates  do  have  an  added  value  in  the  treat- 
ment over  what  we  might  call  the  indifferent 
or  unfavorable  climates,  such,  for  example, 
as  that  of  New  England  in  the  winter,  pro- 
vided always  that  the  other  factors  in  the 
treatment  are  at  hand. 

The  great  mistake  so  often  formerly  made, 
148 


TUBERCULOSIS   AND    CLIMATE 

and  which  has  brought  discredit  upon  cli- 
mate, was  attributing  to  it  more  than  it  could 
alone  and  unaided  perform.  The  consump- 
tive was  so  often  told  to  change  his  climate, — 
go  to  this  or  that  health  resort  and  there  stay 
until  he  got  well  or  worse.  He  was  left  in 
ignorance  of  the  importance  of  the  other  steps 
in  the  treatment,  or  if  he  had  some  inade- 
quate conception  of  them,  it  remained  with 
him  to  carry  them  out  when  and  how  he 
pleased,  or  not  at  all.  If  he  did  not  improve 
Tflnder  these  conditions,  it  was  not  the  climate 
that  was  at  faulty  but  a  disregard  of  the  other 
equally  important  factors  in  the  treatment. 
"  If  I  were  afflicted  with  tuberculosis,"  says 
Dr.  Pottenger,  "  I  would  rather  be  treated  in 
an  intelligent  manner  in  the  most  unfavorable 
climate  than  undertake  to  regain  health  alone 
in  the  best  climate  on  'earth.  .  However,  I  be- 
lieve my  chance  of  cure  would  be  materially 
increased,  if,  combined  with  intelligent  treat- 
ment, favorable  climatic  conditions  were  also 
present." 

By  the  climate  of  any  place,  we  mean  the 
average  weather  conditions  of  that  place, 
which  are  the  temperature,  humidity,  the 
movement  of  the  atmosphere  (the  wind),  the 

149 


TUBERCULOSIS 

condition  of  the  sky  as  to  clouds,  fog,  rain  or 
snow.  By  weather,  we  mean  these  conditions 
observed  at  a  particular  time ;  thus,  the  winter 
climate  of  northern  New  England  is  cold, 
more  or  less  damp,  with  a  considerable  snow 
fall,  and  a  good  deal  of  cloudiness ;  but  the 
zueather  of  any  particular  winter  may  be  com- 
paratively mild  with  little  snow. 

The  Most  Favorable  Climate 

The  kind  of  climate  which  it  has  been 
found  is  most  favorable  for  tuberculosis  is 
one  which  affords  a  large  number  of  pleasant 
sunny  days;  is  dry;  is  not  subject  to  frequent 
and  extreme  changes  of  temperature,  or  to 
high  winds,  and  which  has  a  pure  atmosphere 
as  free  from  dust  as  possible.  It  has  also 
been  found  that  a  cool  or  cold  climate,  such 
as  the  Adirondacks  in  winter,  gives  better  re- 
sults than  a  warm  climate;  the  stimulating 
influence  of  the  cold  is  of  value. 

After  a  careful  investigation,  a  committee 
of  experts  of  the  National  Tuberculosis  As- 
sociation came  to  the  following  conclusions 
regarding  the  value  of  the  different  climatic 
elements  in  the  treatment  of  tuberculosis, 
which,  perhaps,  as  nearly  expresses  the  truth 

150 


TUBERCULOSIS   AND    CLIMATE 

upon  this  subject  as  it  is  possible  to  reach  at 
the  present  time.  They  place  first,  of  course, 
pure  air,  and,  next,  sunshine.  "  The  indirect 
effects  of  sunshine,"  they  say,  "  as  seen  in  the 
powerful  stimulation  of  the  patient's  spirits, 
is  of  great  importance."  Dryness  of  the  air 
is  placed  next,  and  is  regarded  as  a  most  im- 
portant factor.  Equability  of  temperature  is 
not  considered  of  importance,  except  in  th'e 
case  of  elderly  persons  or  the  very  feeble. 
Wind  they  consider  only  harmful  when  the 
patient  is  directly  subjected  to  it.  Altitude, 
as  in  the  mountain  resorts,  such  as  in  Colo- 
rado or  Switzerland,  is  regarded  of  more  or 
less  value  on  account  of  the  greater  purity  of 
the  air,  and  the  stimulating  effect  upon  the 
appetite  and  nutrition.  "  On  the  whole,"  con- 
tinues the  report,  "  low  relative  humidity 
(dryness)  with  moderately  low  or  low  tem- 
perature is  most  generally  suitable,  and  the 
average  tubercular  patient  always  makes  his 
best  gains  in  cold,  dry  weather  where  such 
conditions  prevail." 

Another  influence  of  a  favorable  climate, 
sometimes  forgotten,  is  the  comfort  and  hap- 
piness of  the  patient.  To  make  the  "  cure  " 
under  sunny  skies,  with  the  stimulating  effect 

151 


TUBERCULOSIS 

of  a  dry,  clean  atmosphere  and  the  inspiration 
of  pleasing  scenery,  is  obviously  less  of  a  task 
and  involves  less  monotony  than  taking  the 
treatment  in  a  climate  of  storms,  much  damp- 
ness and  preponderance  of  cloudy  weather. 
Other  things  being  equal,  one  would  prefer  to 
spend  the  days  of  treatment  in  the  sunny 
climate  of  Colorado,  New  Mexico  or  Aiken, 
S.  C,  than  in  the  cloudy  one  of  New  Eng- 
land. A  man  is  happier  and  more  contented 
in  the  sunshine  than  in  the  cloud,  and  content- 
ment goes  a  long  ways  in  the  "  cure."  Indi- 
viduals arriving  in  a  climate,  it  is  said,  where 
the  sun  is  obscured  by  fogs  and  clouds  for 
weeks  at  a  time  suffer  depression  of  spirits, 
loss  of  appetite,  digestive  disturbances  and 
home-sickness. 

Why  a  Change  of  Climate 

In  former  days,  before  the  exact  methods 
of  the  open-air  treatment  were  so  well  estab- 
lished, and  before  there  were  any  sanatoria  in 
the  country,  a  change  of  climate  was  consid- 
ered the  only  thing  which  offered  any  prospect 
of  improvement  or  cure  to  the  tuberculous 
person,  and,  generally,  a  warm  summer  cli- 
mate, like  Florida  or  Bermuda,  was  chosen. 

152 


TUBERCULOSIS   AND    CLIMATE 

The  disease  was  often  not  detected  until  it 
was  well  advanced  and  the  patient  was  hav- 
ing active  symptoms,  such  as  cough,  fever, 
chills,  and  night  sweats,  and,  in  consequence, 
had  become  much  enfeebled.  Or,  if  discov- 
ered early,  it  was  not  considered  serious  until 
these  symptoms  occurred,  particularly  the 
cough.  Under  these  conditions,  it  was  very 
natural  to  select  a  warm,  sunny  climate  where 
one  could  be  made  comfortable  out-of-doors 
with  very  little  exertion  on  his  part.  Comfort 
was  obtained  and  life  prolonged  in  some  cases, 
but  rarely  was  the  disease  cured  or  arrested; 
generally  the  poor  patient  came  home  to  die. 
Later,  after  the  warm  climates  lost  their  popu- 
larity, the  high  altitude  climates  came  into 
notice,  and  in  this  country  Colorado  became 
the  Mecca  for  consumptives,  and  in  Europe 
Davos  became  famous  as  a  tuberculosis 
health  resort  and  remains  so  to  this  day. 

At  the  present  time,  if  the  disease  is  in  an 
advanced  stage,  the  consumptive  is  advised 
to  remain  at  home  as  the  most  suitable  place 
for  his  condition. 

Selection  of  a  Climate 
If  the  disease  is  in  the  early  stage,  without 
153 


TUBERCULOSIS 

fever,  and  a  change  of  climate  is  considered 
desirable,  such  a  one  is  selected  as  will,  in 
conjunction  with  the  other  factors  in  the  open- 
air  treatment,  offer  the  best  prospects  of  cure. 
The  patient  either  goes  to  a  well-conducted 
sanatorium  in  the  resort  selected,  or  else  is 
put  under  the  care  of  an  experienced  physi- 
cian who  carefully  and  constantly  keeps  him 
under  supervision.  Under  such  conditions 
many  cures  are  effected  and  climate  is  made 
valuable. 

When  the  change  of  climate  is  under  con- 
sideration, the  following  points  must  be  care- 
fully determined: 

First:  The  exact  physical  condition  of  the 
patient  and  his  disease, — is  it  a  suitable  case 
to  send  away? 

Second :  What  is  the  climate  best  suited  'to 
him  and  the  stage  of  his  disease? 

Third:  The  sanitary  condition  of  the  re- 
sort selected ;  the  accommodations ;  possibili- 
ties of  obtaining  proper  food;  and  a  reliable 
local  physician. 

Fourth:  The  material  condition  of  the 
patient:  can  he  make  the  change  without 
pecuniary  worry? 

Fifth:   The  influence  of  the  change  of  cli- 

154 


TUBERCULOSIS    AND    CLIMATE 

mate  upon  the  relatives  or  friends  who  may 
accompany  him. 

When  once  the  resort  which  seems  best 
adapted  to  the  case  has  been  selected,  the 
name  and  address  of  a  reliable  physician  at 
the  resort  is  to  be  obtained,  and  the  patient  is 
to  be  placed  under  his  guidance  and  control. 
Any  attempt  of  the  home  physician  to  control 
or  direct  the  treatment  at  a  distance  is  unsat- 
isfactory and  unfair  to  the  patient. 

A  change  of  climate  is  a  serious  matter, 
requiring  a  knowledge  of  climate  and  health 
resorts  on  the  part  of  the  physician,  and 
should  be  advised  only  after  careful  considera- 
tion of  all  the  factors  in  the  case.  Unfortu- 
nately, the  patient  sometimes  makes  a  change 
on  his  own  responsibility  or  on  the  advice  of 
friends, — a  dangerous  thing  to  do.  It  may 
happen  to  be  right,  but  it  is  more  likely  to 
work  irreparable  injury. 

There  are  many  so-called  health  resorts 
which  possess  to  a  greater  or  less  extent  the 
elements  of  climate  which,  as  we  have  seen, 
are  regarded  as  especially  favorable  for  the 
treatment  of  tuberculosis.  There  are  those  of 
greater  or  less  altitude,  and  those  at  or  near 
sea-level;  some  with  a  cold,  rigorous  winter 

155 


TUBERCULOSIS 

climate,  others  with  a  comparatively  mild  one ; 
some  that  are  winter  resorts  only,  and  others 
that  are  serviceable  all  the  year. 

The  Essential  Climatic  Factors 

When  any  health  resort  is  under  considera- 
tion as  applicable  to  a  case  of  tuberculosis, 
we  must  first  learn  the  essential  climatic  facts 
of  the  resort  in  order  to  form  an  opinion  as  to 
its  availability. 

First,  Temperature:  We  must  know  the 
average  daily  temperature  for  the  season  in 
which  one  visits  the  health  resort:  if  a  winter 
resort,  the  average  winter  temperature;  if  an 
all-the-year  resort,  the  average  temperature 
for  the  whole  year.  Then,  it  is  important  to 
know  the  average  daily  range  of  temperature 
in  order  to  judge  of  the  equability  of  the 
climate.  Again,  we  want  to  know  what  ex- 
tremes of  heat  and  cold  have  occurred  in  the 
resort  in  the  past;  for  these  extremes  of  tem- 
perature, as  Dr.  Richards  has  well  put  it,  are 
the  "chances  the  invalid  has  got  to  take  in 
any  resort;  they  do  not  indicate  what  tem- 
perature he  may  expect,  but  what  it  may  be 
his  good  or  evil  fortune  to  encounter." 

Second,  Humidity:  The  humidity  is  an- 
iS6 


TUBERCULOSIS    AND    CLIMATE 

other  important  factor  to  determine  in  order 
to  judge  of  the  dryness  of  the  atmosphere. 
Next  comes  the  average  rainfall;  the  direc- 
tion and  velocity  of  the  wind;  and,  finally, 
what  we  may  call  weather  data,  namely,  the 
average  number  of  clear,  fair,  rainy,  and 
cloudy  days.  This  enables  us  to  determine 
the  amount  of  clear  sky  and  sunshine  one  may 
expect  at  the  resort,  and  hence  the  degree  of 
out-door  life  one  can  enjoy.  If  the  resort  is 
one  in  the  snow  belt,  like  Saranac,  or  Davos 
in  Switzerland,  it  is  important  to  know  the 
amount  of  snowfall  and  the  length  of  time 
snow  lies  continuously  on  the  ground,  and 
when  it  begins  to  melt  in  the  spring. 

Third,  Land  Configuration:  We  must  also 
learn  something  of  the  form  of  the  land, — 
whether  level,  hilly  or  mountainous.  A  hill 
or  mountain  affords  protection  from  high 
winds.  Moderate  ascents  are  often  of  value 
for  exercise,  as  Brehmer  utilized  them  at 
Goerbersdorf  for  his  consumptives. 

Fourth,  Soil :  Again,  we  desire  to  know  the 
character  of  the  soil,  and  the  kind  of  vegeta- 
tion; whether  the  region  is  well-wooded  or 
not,  and  the  character  of  the  forests.  The 
fir,  pine,  spruce  and  other  evergreen  trees  are 

^S7 


TUBERCULOSIS 

generally  considered  an  advantage  to  a  health 
resort  on  account  of  their  shade  and  balsamic 
exudations. 

Fifth,  Facilities  for  Comfortable  Living: 
There  are  other  essential  qualifications  than 
those  of  a  purely  climatic  character  which 
should  be  possessed  by  a  health  resort.  For 
example,  it  is  important  for  the  invalid  to 
know  what  facilities  exist  for  comfortable 
living:  that  the  water  is  pure  and  the  sanitary 
conditions  good,  and  the  board  of  health  ef- 
ficient. He  should  know  that  the  house  he 
is  to  live  in  has  been  efficiently  disinfected,  if 
it  has  been  previously  occupied  by  a  consump- 
tive. He  should  also  find  out  whether  or  not 
he  will  be  received  into  the  hotels  or  even  the 
resorts,  for  many  places  dislike  the  presence 
of  consumptives  and  many  hotels  will  not  re- 
ceive them. 

Various  Health  Resorts  in  America 

There  are  many  resorts  in  this  country 
which  have  proved  their  value  in  the  climatic 
treatment  of  tuberculosis  and  which  still  re- 
tain their  popularity.  The  Adirondacks  have 
become  widely  known,  principally  through 
Dr.  Trudeau  and  the  sanatorium  he  estab- 

158 


TUBERCULOSIS    AND    CLIMATE 

lished  at  Saranac.  Asheville,  North  Carolina; 
Colorado  Springs  and  other  places  in  that 
state;  Southern  CaHfornia;  the  dry  pine  belt 
of  the  South  as  represented  by  the  well-known 
resort  of  Aiken;  New  Mexico;  Arizona;  and 
many  other  places  in  the  great  Southwestern 
plains  and  uplands,  all  possess  favorable  cli- 
matic elements  for  the  open-air  treatment  of 
tuberculosis  and  have  been  extensively  em- 
ployed for  this  purpose. 

The  warm,  moist  climates,  like  the  coast  of 
Florida,  Bermuda,  and  various  islands  in 
southern  latitudes,  are  not  now  regarded  as 
suitable  for  the  effective  treatment  of  tuber- 
culosis: they  are  too  enervating,  and  do  not 
possess  that  stimulating  quality  which  aids 
appetite  and  nutrition.  Long  ocean  voyages, 
once  much  in  vogue  with  the  English,  are  now 
rarely  advised.  The  air  of  the  ocean  is  of 
great  purity,  it  is  true,  but  the  obvious  disad- 
vantages of  an  ocean  voyage  render  this 
method  of  obtaining  the  pure  air  far  inferior 
to  favorable  climatic  resorts  on  land. 


159 


TUBERCULOSIS 

Health  Resorts  in  Europe 

In  Europe  the  best-known  climatic  resorts 
are  in  Switzerland,  the  Black  Forest  and 
Mountains  of  Germany,  and  the  Riviera. 
Davos,  which  has  already  been  mentioned,  is 
the  m.ost  popular  high-altitude  resort,  more 
frequented  in  the  winter  season,  when  the 
snow,  which  covers  the  ground  for  a  long 
;:)eriod,  conduces  to  the  purity  of  the  air.  The 
situation  of  Davos,  however,  in  a  narrow  val- 
ley, renders  the  days  very  short  in  winter,  the 
sun  not  appearing  until  about  ten  o'clock  in 
the  morning  and  setting  about  four  in  the 
afternoon.  The  Riviera  on  the  shore  of  the 
Mediterranean  Sea  has  for  many  years  been 
a  great  winter  resort  for  consumptives. 
The  climate,  however,  is  uncertain  and  the 
*'  mistral,"  the  north  wind,  blows  violently 
at  times.  There  is  much  sunshine  never- 
theless, and  the  attractiveness  of  the  sea 
and  land  scenery  is  most  delightful.  There 
are  many  resorts  in  the  highlands  of  Ger- 
many, in  the  Black  Forest,  the  Bavarian 
and  Hartz  Mountains  and  the  Tyrol,  and 
many  sanatoria  have  been  established  in  these 
regions.     The   only    very    dry   warm    winter 

1 60 


TUBERCULOSIS    AND    CLIMATE 

climate  near  at  hand  to  Europe  is  that  of  the 
Egyptian  desert.  It  exhibits  the  cUmatic 
characteristics  of  arid  regions  in  low  altitudes, 
warmth,  great  purity  of  air,  continuous  sun- 
shine, great  daily  variations  of  temperature, 
dryness  of  the  atmosphere,  and  little  or  no 
rain.  It  is  comparable  in  this  country  to 
Southwestern  Arizona.  Helouan,  Luxor  and 
Assouan  are  the  principal  resorts. 

Dr.  Knopf's  Ideal  Climate 

Dr.  Knopf  has  in  a  single  sentence  well 
summed  up  the  whole  question  of  the  climatic 
treatment  of  tuberculosis.  He  says :  "  The 
ideal  climate  for  the  average  pulmonary  pa- 
tient, in  the  earlier  and  more  hopeful  stages 
of  the  disease,  is  the  one  where  the  extremes 
of  temperature  are  not  great,  with  the  purest 
atmosphere,  relatively  little  humidity,  much 
sunshine,  and  all  the  conditions  which  permit 
the  patient  to  live  comfortably  out-of-doors 
the  largest  number  of  days  out  of  the  year 
and  the  largest  number  of  hours  out  of  the 
twenty-four." 

A  favorable  climate  is  a  valuable  aid  in  the 
treatment  of  tuberculosis,  but  it  must  at  the 
same  time  be  accompanied  by  all  the  other 

i6i 


TUBERCULOSIS 

factors  in  the  open-air  treatment:  competent 
medical  supervision,  abundant  and  good  food, 
rest,  and  all  the  hygienic  conditions  requisite 
for  the  "  cure."  Unless  this  is  the  case,  cli- 
mate will  prove  but  an  elusive  hope. 


162 


X.    THE    PREVENTION    OF    TUBER- 
CULOSIS 

Q RESIDENT  ELIOT  in  an  ad- 
dress to  doctors  upon  "  The  Com- 
ing Change  in  the  Medical  Pro- 
fession," made  the  following 
prophetic  remark :  "  The  proba- 
bility is  that  the  great  part  of  the  work  of 
medical  men  is  hereafter  to  be  done  in  pre- 
ventive medicine."  In  regard  to  tuberculosis, 
preventive  medicine  is  already  a  fact,  and  in 
the  present  world-wide  crusade  against  tuber- 
culosis the  pre-eminent  aim  is  prevention. 

Even  in  the  treatment,  our  efforts  are 
directed  towards  the  early  detection  of  the 
disease  not  only  on  account  of  the  better 
results  obtained,  but  quite  as  much  because 
detected  and  cured  at  their  early  period,  when 
it  is  a  "closed  "  case,  before  the  bacilli  occur 
in  the  sputum,  we  prevent  it  from  becoming 
a  source  of  danger  to  others. 

163 


TUBERCULOSIS 

Two  different  lines  of  attack  are  employed 
in  the  work  of  prevention:  the  one  we  may 
call  the  direct  against  the  germ  itself, — the 
control  of  the  tuberculous  individual  and  his 
sputum,  which  is  the  direct  source  of  danger; 
the  other  we  call  the  indirect,  which  has  for 
its  aim  the  elimination  of  conditions  which 
prepare  the  favorable  soil  for  the  seed,  the 
tubercle  bacillus.  This  includes  all  the  vast 
and  varied  efforts  to  improve  the  social  and 
living  conditions  of  the  masses,  and  so  to  raise 
and  maintain  their  power  of  resistance  to  the 
infecting  germ.  Every  movement  in  this 
direction  is  a  distinct  and  definite  step  in  the 
direction  of  prevention. 

The  Direct  Attack 

Since,  as  we  have  learned,  the  principal 
source  of  infection  is  derived  from  the  sputum 
of  a  consumptive  either  expectorated  or 
coughed  out,  obviously  our  first  effort  is  to 
control  this  primary  source  of  infection.  If, 
indeed,  each  and  'every  consumptive  with 
bacilli  in  his  sputum  could  be  absolutely  con- 
trolled and  made  a  safe  consumptive  as  re- 
gards others,  tuberculosis  would  speedily 
begin  to  diminish  and  continue  to  do  so  with 

164 


ITS    PREVENTION 

increasing  rapidity,  for  we  should  be  con- 
stantly reducing  the  supply  of  the  infecting 
material.  This,  however,  is  obviously  impos- 
sible, although  effort  in  this  direction  is 
steadily  increasing,  as  we  shall  later  see.  The 
difficulty  still  is  that  we  cannot  find  out  all 
the  tuberculous  individuals  in  any  community. 
Many  of  them  do  not  themselves  know  that 
they  have  the  disease,  and  even  if  we  could 
discover  all  cases,  the  difficulties  of  controlling 
them  are  well-nigh  insuperable.  We  can, 
however,  through  educational  means,  accom- 
plish much  by  teaching  the  consumptive  to 
control  himself  and  by  affording  as  free  and 
easy  an  opportunity  as  possible  to  every  one 
to  find  out  whether  or  not  he  has  tuberculosis. 
In  some  cases  an  examination  of  the  lungs 
can  be  required  as  a  condition  of  employment, 
for  example,  as  is  already  done  in  some  estab- 
lishments. Education  in  the  simple  facts  of 
tuberculosis  has  already  accomplished  much 
in  this  direction. 

The  Educational  Campaign 

The  educational  campaign  against  tuber- 
culosis has  now  become  a  mighty  movement. 
In  'every  civilized  country  of  the  world  the 

165 


TUBERCULOSIS 

people  are  now  being  taught  what  causes 
tuberculosis  and  how  to  avoid  it.  They  are 
learning  that  the  sputum  carelessly  scattered 
about  and  becoming  dry  is  the  cause  of  the 
disease,  and  that  if  this  is  destroyed  before 
it  becomes  dry,  the  disease  cannot  be  con- 
veyed to  another.  Such  tuberculosis  educa- 
tion, then,  is  one  form  of  direct  attack,  for  it 
teaches,  as  we  have  said,  the  consumptive  to 
control  himself  and  the  non-consumptive  to 
control  his  careless  consumptive  neighbor,  or 
see  that  he  is  controlled. 

The  method  of  conducting  this  great  edu- 
cational propaganda  is  familar  to  all;  almost 
every  device  is  employed  which  will  attract 
and  interest  the  public. 

The  Tuberculosis  Exhibition 

The  most  generally  popular  method  has 
been  the  tuberculosis  exhibition,  which  has 
grown  from  small  beginnings  to  the  great  in- 
ternational one  exhibited  in  Washington  in 
connection  with  the  International  Congress 
on  Tuberculosis  in  1908.  Here  was  shown 
in  the  most  extensive  and  graphic  way  what 
the  various  states  of  this  country  and  the 
nations  of  Europe  are  doing  in  the  prevention, 

166 


ITS    PREVENTION 

study  and  cure  of  tuberculosis.  It  was  a  mar- 
velous exhibition,  and  one  could  spend  weeks 
in  its  study.  Later,  when  it  was  moved  to 
New  York,  no  less  than  753,301  persons 
visited  it  during  the  seven  weeks  of  its  stay 
there.  One  can  gain  some  idea  of  its  magni- 
tude from  the  fact  that  it  took  ten  special  cars 
to  transport  it  from  Washington  to  New  York. 
One  striking  feature  of  the  exhibition  is  worth 
while  mentioning  just  here.  Against  a  board 
suspended  between  two  balconies  were  three 
incandescent  lights,  which  at  regular  intervals 
for  an  instant  were  extinguished  and  then 
flashed  out  again.  Under  the  lights  was  this 
sentence :  "  These  lights  go  out  every  two 
minutes  and  thirty-six  seconds.  Every  time 
the  lights  go  out  someone  dies  of  tuberculosis. 
Tuberculosis  is  communicable,  curable,  pre- 
ventable." There  was  always  a  group  of 
people  in  front  of  this  design  silently  watching 
the  lights. 

The  Traveling  Exhibition 

Smaller  exhibitions  go  from  state  to  state 
and  city  to  city,  some  under  the  auspices  of 
the  National  Tuberculosis  Association,  and 
others  under  local  or  state  associations.  These 

167 


TUBERCULOSIS 

"  traveling  exhibitions "  consist  of  charts, 
photographs,  maps,  models,  diagrams,  legends, 
and,  in  brief,  a  great  variety  of  material  illus- 
trating the  study,  prevention  and  treatment  of 
tuberculosis.  Such  exhibitions  are  well  ad- 
vertised beforehand  in  the  local  press,  etc., 
and  during  the  time  of  exhibition  lectures  are 
given,  often  with  stereopticon  illustrations, 
and  literature  distributed  free.  Every  effort 
is  made  to  arouse  the  interest  of  all  the  people 
in  the  city  visited.  In  some  exhibitions  a 
phonograph  with  its  tireless,  if  strident  and 
monotonous  voice,  repeats  tuberculous  apho- 
risms. 

In  the  traveling  exhibit  of  the  Boston 
Tuberculosis  Association  was  a  realistic  repre- 
sentation of  two  rooms  side  by  side :  one,  a 
dark,  dirty,  disordered  tenement  house  room, 
wretched  in  the  extreme ;  and  the  other,  a 
neat,  clean,  simply  furnished  room,  with  the 
fresh  air  and  light  coming  in  through  the 
window.  One  is  labeled  "  The  wrong  kind  of 
a  room,"  and  the  other  "  The  right  kind  of  a 
room."  This  feature  of  the  exhibit  always 
attracts  much  attention.  On  one  occasion  a 
little  girl,  after  silently  looking  at  both  rooms, 
remarked  to  her  father  who  was  with  her: 
"  Papa,  our  rooms  look  just  like  this  one  " 
(pointing  to  "the  wrong  kind  of  a  room"). 

1 68 


ITS    PREVENTION 

"  WeVe  got  to  move,  or  we  will  all  die  of 
consumption." 

Moving  picture  plays  are  now  employed  to 
illustrate  various  phases  of  the  tuberculosis 
problem,  and  the  motion  picture  and  vaude- 
ville theaters  have  been  utilized  for  brief  illus- 
trated talks  upon  tuberculosis.  In  the  summer 
of  igi2,d.  seven-minute  illustrated  lecture  upon 
"  An  Out-door  Life  for  Health  "  was  given  in 
32  motion  picture  theaters  in  Boston,  340  times 
to  a  total  number  of  143,635  persons. 

The  Service  of  the  Public  Press 

The  public  press  has  entered  into  the  educa- 
tional campaign  with  great  zeal  and  has  im- 
mensely aided  the  movement.  Through  the 
press  service  of  the  National  Association 
timely  articles  upon  tuberculosis  are  furnished 
the  newspapers  of  the  country.  From  recent 
statistics  collected  by  the  National  Associa- 
tion, the  various  newspapers  of  the  United 
States  printed  articles  concerning  tuberculosis, 
which,  when  measured,  amounted  to  over 
50,000  column  inches  of  space  in  two  weeks. 
If  all  this  matter  were  gathered  together  at 
one  time,  it  would  make  a  newspaper  of  the 
ordinary  size,  of  359  pages  of  solid  printed 
matter,  without  any  advertisements,  all  on  the 
subject  of  tuberculosis.     If  it  were  arranged 

169 


TUBERCULOSIS 

in  one  long  chain,  it  would  make  a  single 
column  four-fifths  of  a  mile  long  and  two  and 
one-quarter  inches  wide.  Tuberculosis,  then, 
is  receiving  *'  half  a  mile  of  publicity  a  week," 
as  the  National  Association  says. 

Popular  illustrated  lectures,  pamphlets,  leaf- 
lets, illustrated  placards,  issued  by  states, 
cities,  boards  of  health  and  tuberculosis  asso- 
ciations, still  further  disseminate  tuberculosis 
knowledge,  so  that  it  would  seem  that  soon 
every  individual  must  have  learned  the  simple 
facts  concerning  the  prevention  of  tubercu- 
losis. School  books  on  physiology  and  hy- 
giene now  include  the  subject  of  tuberculosis, 
and  in  the  State  of  Massachusetts,  and  per- 
haps in  others,  instruction  upon  the  preven- 
tion of  the  disease  is  required  by  law  to  be 
given  in  all  public  schools. 

Compulsory  Notification 

Another  direct  means  of  attack  is  compul- 
.sory  notification,  that  is,  a  law  requiring  all 
physicians  and  hospitals  to  notify  the  board 
of  health  of  every  case  of  tuberculosis  coming 
under  their  observation,  on  the  ground  that 
tuberculosis  is  a  contagious  disease  and  there- 
fore dangerous  to  the  public  health.  Such 
compulsory  notification  is  now  required  in  a 
number  of  states  and  practically  all  the  larger 

170 


ITS    PREVENTION 

cities  in  this  country  and  in  various  countries 
abroad.  The  object  of  this  requirement  is  to 
enable  the  health  authorities  to  locate  the 
cases  of  tuberculosis  and  keep  them  under 
supervision.  This  applies  more  particularly 
to  crowded  living  localities  where  the  dangers 
of  infection  are  greatest.  This  law  requiring 
notification  is  not  intended  to  disturb  the  con- 
sumptive, but  to  make  sure  that  he  and  his 
family  are  properly  instructed  as  to  the  care 
of  the  sputum  and  the  avoidance  of  infection, 
— it  helps  the  consumptive  and  protects  his 
family. 

Another  important  means  o£  prevention  is 
the  free  examination  of  suspected  sputum  in 
state  and  city  laboratories,  as  has  been  before 
referred  to.  If  the  sputum  is  found  to  con- 
tain the  tubercle  bacilli,  the  health  authorities 
are  thus  informed  of  the  existence  of  the  case 
and  where  it  is  situated. 

Again,  laws  and  ordinances  against  indis- 
criminate spitting  in  public  places  is  a  pre- 
ventive measure.  Some  of  the  dangers  from 
this  vulgar  habit  have  been  already  considered. 
If  a  consumptive  is  obliged  to  go  about,  he 
can  provide  himself  with  a  pocket  flask,  or 
some  pieces  of  cloth  or  Japanese  napkins, 
which,  after  being  used,  can  be  deposited  in 
a  paper  or  rubber  bag;  or  one  can  have  a 

171 


TUBERCULOSIS 

rubber-lined  pocket,  and  on  returning  home 
the  sputum  can  be  burned. 

It  has  been  found  that  laundry  workers 
suffer  severely  from  tuberculosis,  probably 
through  infection  from  contaminated  linen: 
hence,  the  importance  of  first  boiling  all  ar- 
ticles before  being  handled  or  washed.  With 
a  known  consumptive,  all  his  soiled  linen 
should  be  put  in  a  bag  by  itself  and  boiled. 

The  Tuberculosis  Dispensary 

The  free  tuberculosis  dispensary,  a  com- 
paratively modern  development  in  the  warfare 
of  prevention,  is  an  instrument  of  preventive 
medicine,  the  value  of  which,  as  Dr.  Philip 
of  Edinburgh,  who  estabhshed  one  of  the  first 
institutions  of  the  kind,  says,  it  would  be  dif- 
ficult to  overestimate.  Its  value  is  not  so 
great  in  treating  the  poor  consumptive,  im- 
portant as  that  is,  as  it  is  in  protecting  his 
family  and  the  community.  The  dispensary 
affords  a  free  and  easy  opportunity  to  every 
poor  person  for  an  examination  of  his  lungs 
if  he  suspects  he  has  tuberculosis.  In  this 
way  many  early  cases  are  discovered  and  given 
timely  treatment.  When  a  case  is  discovered, 
the  visiting  nurse  goes  to  the  patient's  home, 
investigates  the  hygienic  conditions,  shows  the 
patient  how   to  live   so  as   not  to   endanger 

172 


ITS    PREVENTION 

other  members  of  the  household,  and,  what  is, 
perhaps,  the  most  important  part  of  all,  urges 
all  the  members  of  the  family  to  be  examined 
at  the  dispensary.  Thus  other  cases  in  the 
same  home  are  not  infrequently  discovered. 
This  home  inspection  is  repeated  periodically, 
and  the  consumptive  is  never  lost  sight  of. 
From  the  view-point  of  prevention,  the  protec- 
tion of  the  consumptive's  family  is  the  chief 
consideration.  Almost  every  city  now  con- 
tains one  or  more  such  dispensaries,  and  some 
of  them  are  opened  at  night  for  the  accommo- 
dation of  those  who  have  to  work  by  day. 

The  Isolation  of  the  Dangerous  Consumptive 

Do  what  we  will  through  education  and  the 
dispensary,  with  its  visiting  nurse  and  home 
supervision,  there  will  always  remain  a  cer- 
tain number  of  consumptives  who  are  far 
advanced  in  the  disease  and  in  a  hopeless 
condition,  who,  through  ignorance,  helpless- 
ness or  wilfulness  will  not  safely  dispose  of 
their  sputum  and  who  thus  expose  to  the  in- 
fection other  members  of  the  household.  Such 
cases  are  always  found  in  the  homes  of  the 
poor.  What  shall  we  do  with  these  sources 
of  infection?  The  only  way  is  to  remove 
them  to  consumptive  hospitals  and  thus  isolate 

173 


TUBERCULOSIS 

them.  This  is  no  hardship  to  the  poor  bed- 
ridden consumptive,  for  he  will  receive  far 
better  attention  than  in  his  miserable  home. 
"  The  advanced  consumptive,"  says  Dr. 
Jacobi,  "  is  the  real  danger  to  the  family  and 
community.  A  dying  consumptive  should  be 
removed  to  a  healthy,  comfortable  place  to 
die  in  without  endangering  the  community; 
this  is  the  only  way  in  which  the  epidemics  of 
chronic  diseases  may  become  extinct." 

Mr.  Schiff,  President  of  the  Montefiore 
Home,  declares  that  the  isolation  of  phthisis 
sufferers  in  an  advanced  stage  should  be 
made  compulsory  by  law.  It  is  well  known 
that  no  general  hospital  will  now  receive  in 
its  wards  persons  suffering  from  tuberculosis 
on  account  of  the  danger  of  infecting  other 
patients ;  therefore,  especial  hospitals  must  be 
established  for  the  advanced  consumptive,  and 
such  hospitals  are  the  greatest  need  in  the 
United  States  at  this  time,  and  this  is  being 
done  in  a  number  of  States  by  the  establish- 
ment of  local  consumptive  hospitals,  as  in 
New  York,  Minnesota  and  Massachusetts. 
The  state  sanatorium  has  been  and  is  a  more 
popular  movement,  but  the  greater  need  from 
the  point  of  prevention  is  consumptive  hos- 
pitals for  the  advanced  and  dangerous  cases, 
whose  isolation  will  undoubtedly  do  more  to 

174 


ITS    PREVENTION 

prevent  and  control  the  disease  than  any  other 
one  means. 

"There  can  be  no  manner  of  doubt,"  says 
Dr.  Philip,  before  quoted,  "  that  the  far-ad- 
vanced or  dying  cases  constitute  the  greatest 
source  of  infection."  Dr.  Newsholme,  a 
medical  health  officer  of  England,  after  a 
very  thorough  and  painstaking  investigation 
into  the  disease,  and  the  life  and  environment 
of  the  people  which  influence  it,  found  that 
the  diminution  of  tuberculosis  bears  a  con- 
stant relation  to  the  amount  of  institutional 
segregation — of  isolation  in  hospitals — that 
the  greater  the  hospital  accommodations  for 
isolation  the  greater  the  diminution  of  tuber- 
culosis. In  England  and  Wales,  Dr.  News- 
holme  says  that  a  large  and  continuously  in- 
creasing amount  of  institutional  segregation 
has  been  uniformly  accompanied  for  nearly 
40  years  by  a  large  and  continuous  decrease 
of  the  disease.  None  of  the  other  indirect 
means,  he  says,  whether  it  be  less  crowding, 
diminution  of  poverty,  increase  in  wages,  bet- 
ter food,  shorter  hours  of  labor,  etc.,  though 
they  have  had  an  assured  influence,  has  shown 
such  uniform  variation  with  the  death  rate 
from  tuberculosis  as  has  isolation. 

London  itself,  which  has  for  many  years 
possessed  a  number  of  large  hospitals  for  con- 

175 


TUBERCULOSIS 

sumptives,  has  a  low  death  rate  from  the 
disease,  13.46  per  10,000 — less  than  half  that 
of  Paris,  in  which  latter  city,  although  a  large 
proportion  of  consumptives  enter  hospitals, 
they  remain  but  a  few  days,  and  hence  such 
short  isolation  cannot  have  much  influence  in 
reducing  the  total  infection.  In  New  York 
City,  where  the  diminution  of  tuberculosis  has 
been  marked  and  rapid,  from  42.7  per  10,000 
in  1881,  to  16.6  in  1912,  every  case  of  ad- 
vanced disease  has  an  opportunity  of  being 
treated  and  isolated  in  a  hospital  on  an  aver- 
age of  twenty-one  weeks  and  liberal  provision 
has  been  made  by  the  city  for  this  purpose. 

Disinfection 

Another  direct  preventive  measure  is  the 
disinfection  and  renovation  of  the  premises 
which  have  been  occupied  by  a  tuberculous 
individual.  Since  tuberculosis  is  now  classed 
with  the  other  infectious  or  contagious  dis- 
eases in  most  communities,  the  law  requiring 
disinfection  for  such  diseases  applies  to  tuber- 
culosis. 

Infected  rooms  of  tenements  have  been 
found  to  be  instrumental  in  conveying  the  dis- 
ease to  new  and  unsuspecting  tenants.  In 
the  "  Lung  Block "  in  New  York  City,  265 

176 


ITS    PREVENTION 

cases  of  tuberculosis  were  reported  to  the 
board  of  health  in  nine  years,  and  undoubt- 
edly some  of  these  were  caused  by  the  infec- 
tion in  the  rooms  from  consumptives  who  had 
previously  occupied  them.  Cornet  and  other 
investigators  have  proved  that  the  dust  in  the 
rooms  which  were  occupied  by  unclean  con- 
sumptives contained  the  tubercle  bacilli.  Of 
311  animals  inoculated  with  dust  from  rooms 
occupied  by  consumptive  patients,  Cornet 
found  that  167  died  soon  after  infection,  59 
were  tuberculous,  and  85  were  healthy.  A 
room  in  a  hotel  occupied  by  a  consumptive 
actress,  and  a  workshop  occupied  by  a  tailor 
who  had  directly  communicated  the  disease  to 
a  fellow-workman,  were  found  infected.  But 
in  no  case  was  the  dust  of  the  walls  infectious 
when  sputum  cups  were  used  exclusively  to 
receive  the  expectorated  matter. 

Dr.  Ransome  cites  an  instance  from  Laen- 
nec's  writing  of  a  religious  community  of 
women  kept  in  strict  seclusion  and  with 
somber  surroundings,  in  which  Laennec  had 
seen  consumption  arise  so  frequently  that  in 
ten  years'  time  the  population  of  the  institu- 
tion had  been  two  or  three  times  renewed 
owing  to  the  mortality  of  the  inmates, — with 
the   significant  exception  of  those   who  had 

177 


TUBERCULOSIS 

charge  of  the  gardens,  the  kitchen  and  the 
infirmary.  Undoubtedly  much  of  this  mor- 
taHty  from  tuberculosis  was  caused  by  infected 
rooms,  for  in  those  days  the  infectious  nature 
of  tuberculosis  was  unknown. 

We  see,  then,  how  important  it  is,  from  the 
standpoint  of  prevention,  to  thoroughly  clean 
all  offices,  workshops,  school  rooms,  etc.,  and 
in  dusting  to  use  moist  [cloths  and  wet  brooms, 
or,  better,  the  modern  method  of  vacuum  re- 
moval of  the  dust.  In  factories  and  work- 
shops the  cleaning  and  dusting  should  be  done 
after  the  day's  work,  so  that  there  should  be 
no  dust  in  the  air  when  the  occupants  re- 
assemble the  next  day. 

Compulsory   Notification   and   Disinfection 
No  New  Thing 

Compulsory  notification  and  disinfection  for 
tuberculosis  is  no  new  thing,  for  a  hundred 
years  or  more  ago  the  King  of  Naples  issued 
the  following  remarkable  decree,  almost  pro- 
phetic in  view  of  what  we  know  and  do  to- 
day :  "  Every  physician,"  runs  the  edict,  "  is 
henceforth  required  to  report  to  the  author- 
ities every  case  of  consumption  the  instant 
it  is  recognized.  Failing  this  a  fine  of  400 
ducats  will  be  exacted,  and  for  a  second  of- 

178 


ITS    PREVENTION 

fense  banishment  for  ten  years.  Poor  pa-« 
tients  should  at  once  he  taken  to  the  hospital. 
Their  clothing  and  linen  shall  be  kept  and 
cared  for  apart  from  other  patients.  In  case 
of  death  every  article  must  be  produced  and 
identified  by  the  hospital  superintendent.  Any 
infringement  of  this  law  may  be  punished  by 
imprisonment  or  the  galleys.  It  is  the  duty 
of  those  in  authority  to  renovate  the  room  of 
a  former  patient,  floor,  hangings  and  furni- 
ture coverings;  to  burn  the  window  frames 
and  doors  and  replace  them  by  new  ones. 
The  extreme  penalty  of  the  law  will  be  vis- 
ited on  anyone  buying  or  selling  the  effects 
of  phthisical  (consumptive)  patients.  Every 
house  where  a  consumptive  dies  shall  be  black- 
listed." In  Florence  similar  laws  were  en- 
acted. 

In  New  York  City  no  tenement  is  permitted 
to  be  occupied  again  after  the  death  of  a 
consumptive  until  disinfection  has  been  done 
to  the  satisfaction  of  the  board  of  health, 
which  performs  this  office  free.  This  is  also 
required  in  some  health  resorts  and  should  be 
in  all. 

The  fundamental  idea  in  disinfection  is 
really  cleanliness,  *'  surgical  cleanliness,"  as 
one  might  call  it.     Indeed,  if  absolute  cleanli- 

179 


TUBERCULOSIS 

ness  were  always  maintained  in  the  sick  room 
of  the  consumptive,  there  would  be  no  need 
of  disinfection,  as  the  experiments  of  Cornet, 
above  cited,  have  shown,  for  in  rooms  where 
the  sputum  was  properly  disposed  of,  no  tu- 
bercle bacilli  were  found  in  the  dust.  But 
as  we  can  never  be  sure  of  this  ideal  clean- 
liness, we  must  safeguard  the  after-comers 
by   disinfection. 

Methods  of  Disinfection 

There  are  various  methods  of  disinfection 
in  use.  The  one  perhaps  most  generally 
adopted  is  a  thorough  fumigation  with  formal- 
dehyde gas,  the  room  being,  as  far  as  possi- 
ble, hermetically  sealed  by  putting  strips  of 
paper  and  cotton  over  the  window  and  door 
cracks  or  wherever  the  gas  can  escape.  In 
addition  the  painted  wood  work  is  scrubbed 
with  a  solution  of  hot  soda,  and  the  walls  are 
repainted  and  repapered  after  being  thoroughly 
cleansed.  All  hangings,  bedding,  mattresses, 
pillows  and  rugs  are  disinfected  with  steam, 
or  exposed  to  the  air  and  sunlight  for  several 
days,  and  all  articles  of  little  value  are 
burned.  The  mere  fumigation  of  the  room 
is  not  sufficient.     Renovation  is  also  neces- 

i8o 


ITS    PREVENTION 

sary, — indeed,  renovation  in  conjunction  with 
scrubbing  and  washing  the  room  is  probably 
more  important  and  efficient  than  mere  fumi- 
gation. Either  before  or  after  the  disinfec- 
tion the  exposure  of  the  room,  by  means  of 
wide  open  windows,  to  the  fresh  air  and  sun- 
light for  several  days,  is  a  useful  precaution. 

The  whole  essence  of  direct  prevention  is, 
in  a  word,  cleanliness,  which,  applied  to  the 
consumptive,  means  the  proper  and  safe  dis- 
posal of  the  sputum,  whether  expectorated 
or  coughed  out,  for  "  no  spit,  no  consump- 
tion," and  a  clean  consumptive  is  a  safe  one 
at  home  or  abroad.  So  long,  however,  as 
the  unclean  consumptive  is,  unfortunately,  al- 
ways to  be  found  somewhere,  we  must  either 
teach  him  to  be  clean,  clean  up  after  him,  or 
isolate  him  in  a  hospital ;  for,  in  his  efforts 
to  cure  himself,  he  has  no  right  to  jeopardize 
the  well  community. 

The  danger  from  the  unclean  consumptive 
is  all  the  greater  from  the  fact  that  the  infec- 
tion is  so  slow  and  insidious  in  its  action.  An 
individual  may  become  infected  and  experi- 
ence no  immediate  results  from  it;  the  infec- 
tion may  lie  dormant  in  him  for  years,  and 
then  on  a  favorable  occasion  become  active. 

i8i 


TUBERCULOSIS 

On€  seldom  obtains  a  history  of  any  known 
exposure  to  infection  from  some  other  con- 
sumptive; yet  it  must  have  sometime  in  the 
past  occurred  and  been  forgotten. 

The  Indirect  Means  of  Prevention 

The  indirect  attack  in  the  v^arfare  of  pre- 
vention is  directed  against  the  human  soil,  and 
consists  in  efforts  to  render  it  unfavorable 
for  the  growth  of  the  tubercle  bacillus.  We 
have  already  seen  what  influences  tend 
towards  the  production  of  a  favorable  soil, 
and,  consequently,  the  problem  in  this  in- 
direct attack  is  to  combat  and  correct  these 
vicious  conditions. 

"  Before  any  vice,"  says  Dr.  Holmes,  "  can 
fasten  on  a  man,  body,  mind,  or  moral  nature 
must  be  debilitated."  It  is  the  debilitated 
body  which  offers  the  favorable  soil  for  tu- 
berculosis, and,  therefore,  the  influences  which 
produce  this  condition  must  be  removed  and 
the  body  raised  to  and  maintained  at  a  re- 
sistant level.  All  the  numberless  instrumen- 
talities for  improving  the  public  health,  famil- 
iar to  us  all,  are  effective  weapons  in  this 
warfare;  indeed,  before  the  discovery  of  the 
cause  of  tuberculosis,  imoroved  sanitary  and 

182 


ITS    PREVENTION 

hygienic  conditions  were  already  decreasing 
the  mortahty  and  prevalence  of  tuberculosis, 
and  they  are  still  most  influential,  in  conjunc- 
tion with  the  direct  means  of  control,  in  the 
further  diminution  of  the  disease. 

Tuberculosis  a  Social  Disease 

Tuberculosis,  as  we  have  said,  is  often 
called  a  "  social "  disease,  because  the  social 
conditions,  the  conditions  of  living  and  work- 
ing, are  so  influential  in  its  production,  and 
in  its  prevention.  In  the  struggle  to  improve 
the  social  condition  of  the  masses,  we  must 
strive  for  better  homes  for  the  working  peo- 
ple, less  crowding,  shorter  hours  of  work  in 
many  employments,  and  better  wages;  better 
sanitary  conditions  and  ventilation  in  work- 
shop and  factory;  more  thorough  school  in- 
spection and  care  of  weakly  children;  open- 
air  schools  and  open-air  school  rooms;  the 
prohibition  of  child  labor,  and  the  limitation 
of  hours  of  work  for  women  in  factories  and 
shops, — protection  of  mothers;  opportunities 
for  out-door  life  by  play  grounds  and  parks; 
provision  for  wholesome  recreation  and 
amusement;  pure  and  sufficient  food,  clean 
milk;  public  baths;  better  environments  for 
child  life ;  care  of  the  teeth  of  children  through 

183 


TUBERCULOSIS 

free  dental  clinics ;  instruction  in  hygiene ; 
fewer  saloons,  and  morally  clean  cities  and 
towns.  In  every  department  of  social  effort 
and  uplift  the  worker  is  indirectly  but 
none  the  less  surely  and  effectively  combating 
tuberculosis.  "  All  social  activities,"  says  Dr. 
Routzahn,  "  touch  this  problem  of  tubercu- 
losis, and  we  can  make  its  consideration  a 
medium  to  agitate  for  social  betterment.  Its 
final  solution  depends  on  the  solution  of  all 
the  complex  social,  political  and  economic 
problems  of  the  day." 

Someone  has  called  the  tuberculosis  war- 
fare one  of  "  enlightened  selfishness  "  because 
the  motive  of  self-preservation  is  a  powerful 
impelling  factor  in  it.  Although  the  disease 
is  far  more  prevalent  among  the  poor  than 
the  rich,  for  the  latter  live  under  favorable 
hygienic  conditions,  still  the  tubercle  bacillus 
is  an  ubiquitous  germ,  and  the  possibility  of 
contracting  the  disease  is  never  absent  from 
anybody.  A  consumptive  servant,  for  exam- 
ple, may  infect  a  member  of  the  household 
where  she  serves;  or  a  tuberculous  nurse  girl 
the  child  she  cares  for:  hence  all  are  selfishly 
and  personally  interested  in  taking  a  hand  in 

184 


ITS    PREVENTION 

the  great  warfare  and  working  in  some  of  the 
many  ways  of  control  and  prevention,  direct 
or  indirect.  What  a  profound  sigh  of  reHef 
the  world  will  emit  when  finally  tuberculosis, 
as  has  happened  with  most  of  the  other  great 
infectious  diseases,  as  we  have  seen,  shall 
have  practically  disappeared !  and  it  is  within 
the  power  of  man  to  do  it,  for  it  is  a  prevent- 
able disease. 

Three  of  the  most  vital  points  of  attack 
in  the  indirect  means  of  prevention  are  over- 
crowding, alcoholism,  and  impure  in-door  air, 
all  of  which  have  been  discussed  in  the  chap- 
ter upon  the  "  Seed  and  the  Soil."  We  have 
seen  that  overcrowding  means  dirt,  vitiated 
air  and  greater  opportunities  for  infection, 
and  in  the  illustration  of  living  conditions 
in  Paris  and  London  we  have  seen  that  tuber- 
culosis increased  with  overcrowding. 

Better  Tenement  Houses 

The  healthy  housing  of  the  poor  in  model 
tenements  in  the  city,  or  cheap  and  rapid 
transportation  to  the  suburbs  and  the  pro- 
vision of  proper  homes  there,  must  be  accom- 
plished if  we  are  to  succeed  in  the  struggle. 

185 


TUBERCULOSIS 

Recently  both  the  municipaHties  and  philan- 
thropists have  recognized  the  pressing  im- 
portance of  the  housing  problem  in  the  city, 
and  much  has  been  done  in  the  way  of  more 
stringent  laws  for  tenement  house  building 
and  inspection,  and  in  the  erection  of  whole- 
some, well-ventilated  tenements.  In  the  writ- 
er's opinion,  the  final  solution  of  the  housing 
problem  will  be  cheap,  rapid  transportation  to 
land  in  the  suburbs. 

Prohibition  of  Liquor 

We  have  also  seen  that  among  intemperate 
persons  an  excessive  death  rate  from  tuber- 
culosis prevails.  Dr.  Bertillon,  the  eminent 
French  statistician,  has  shown  that  tubercu- 
losis is  twice  as  prevalent  among  the  retail 
liquor  dealers  of  France  as  among  other  shop- 
keepers. In  the  prevention  of  tuberculosis, 
therefore,  the  saloon  must  be  controlled,  or 
eliminated.  If  for  no  other  reason  than  the 
prevention  of  tuberculosis.  State  prohibition 
would  be  amply  justified;  and  one  can  only 
regard  with  profound  satisfaction,  from  a 
tuberculosis  standpoint.  State  prohibition  and 
no  license  in  the  cities.  But  behind  prohibi- 
tion must  come  better  living  conditions,  nutri- 
tious  food,   fresh  air,   and  innocent  amuse- 

i86 


ITS    PREVENTION 

merits,  to  take  the  place  of  the  saloon  and 
alcohol. 

Pure  Air 

It  is  a  self-evident  proposition  that  the  con- 
tinued breathing*  of  impure  air  lowers  one's 
vitality;  and,  consequently,  good  ventilation, 
letting  in  the  fresh  air  to  our  houses,  offices, 
schools,  public  buildings,  workshops  and  pub- 
lic vehicles,  is  a  measure  of  the  first  impor- 
tance in  the  indirect  prevention  of  tubercu- 
losis. Nowhere,  perhaps,  is  such  impure,  foul 
air  met  with  as  in  the  city  street  cars  in  win- 
ter, though  some  of  our  churches  are  equally 
as  grave  sinners  in  this  respect.  The  public 
are  largely  at  fault  for  this  condition:  they 
are  afraid  of  fresh  air ;  they  want  to  be  com- 
fortable, and  when  the  choice  lies  between 
impure  air  and  warmth,  which  makes  them 
comfortable,  and  ventilation,  which  may  mean 
a  little  colder  air  and  which  at  first  is  a  little 
less  comfortable,  they  will,  or  the  average 
person  will,  choose  the  former  alternative. 

It  is  so  often  erroneously  beHeved  that  cold 
air  and  draughts  produce  colds.  Pure  air,  as 
we  have  seen,  never  does  this,  for  colds  are 
caught  from  some  one  else  suffering  from 
them,  or  from  the  infection  scattered  about 
by  them.  Nansen,  the  Arctic  explorer,  en- 
dured all  sorts  of  exposure  to  cold  and  wet 

187 


TUBERCULOSIS 

on  his  Arctic  expedition,  yet,  he  tells  us,  he 
never  had  a  cold  until  he  returned  to  civil- 
ized life  and  slept  in  a  house.  With  a  little 
training  and  hardening  one  can  learn  to  sit 
in  his  office  or  eat  his  dinner  with  an  open 
window  and  enjoy  the  stimulation  of  the  cool 
fresh  air,  even  in  the  midst  of  winter. 

One  of  the  valuable  incidental  benefits  of 
this  great  tuberculosis  campaign  is  the  em- 
phasis laid  upon  the  importance  of  fresh  air. 
If  fresh  air  will  accomplish  such  marvelous 
results  in  the  treatment  of  tuberculosis  as  it 
does,  then  it  must  be  good  for  those  who  are 
well  and  desire  to  avoid  the  disease.  The 
gospel  of  fresh  air  has  never  been  so  inces- 
santly and  universally  proclaimed  as  it  is  to- 
day in  connection  with  the  prevention  and 
cure  of  tuberculosis.  Once  one  becomes  ac- 
customed to  an  abundance  of  fresh  air,  he 
will  crave  it  almost  as  the  drunkard  does  his 
dram,  and  he  will  never  again,  if  he  can  avoid 
it,  subject  himself  to  the  misery  of  impure 
air. 

What  has  been  said  above  regarding  the 
prevention  of  tuberculosis  applies,  of  course, 
to  the  individual  as  well  as  to  the  public  at 
large ;  but  there  are  certain  precautions  which 

i88 


ITS    PREVENTION 

have  a  mora  direct  personal  application  and 
which  it  will  be  well  to  mention. 


Important  Points  to  Remember 

In  the  first  place,  if  one  has  a  "  poor  con- 
stitution," as  we  say,  and  is  not  strong  and 
robust,  an  out-door  occupation  is  preferable 
to  confinement  in-doors ;  but  if  he  is  unable 
to  do  this,  he  should  take  especial  measures 
to  strengthen  his  body,  by  exercise  out-of- 
doors,  winter  and  summer,  deep  breathing, 
plain  and  wholesome  food,  well  prepared,  well 
chewed  and  taken  at  regular  times,  and  by 
sufficient  rest  and  sleep  with  an  abundance 
of  fresh  air  in  the  bedroom, — and,  in  brief, 
an  observance  of  all  the  laws  of  health  and 
avoidance  of  all  excesses. 

The  average  person  should  sleep  at  least 
eight  hours,  alone,  in  a  well-ventilated  room, 
and  should  breathe  through  the  nose  with  the 
mouth  shut. 

If  a  cold  bath  is  good  for  a  tuberculous 
individual,  it  is  equally  so  for  a  well  person^ 
and  one  should  form  the  habit  of  taking  it 
every  morning.  The  teeth  should  be  brushed 
at  least  after  breakfast  and  at  night  on  retir- 

189 


TUBERCULOSIS 

ing.  The  mouth  should  be  frequently  rinsed, 
and  the  hands  washed  before  eating.  "  Let 
order  and  cleanliness  have  the  first  place  in 
the  whole  conduct  of  life." 

A  cold  or  cough  should  not  be  neglected, 
and  if  any  of  the  early  symptoms  of  tuber- 
culosis mentioned  in  Chapter  VI  are  observed, 
one  should  immediately  consult  a  physician. 
If  it  can  be  avoided,  one  should  not  sleep  in 
a  room  with  a  consumptive,  and  if  he  is 
obliged  to  live  in  a  house  with  one,  or  work 
in  an  office  or  shop  near  one,  he  should  see 
that  he  properly  disposes  of  his  sputum  and 
holds  something  before  his  mouth  when 
coughing.  One  should  not  put  the  fingers 
in  the  mouth  or  nose,  or  any  unclean  thing, 
such  as  money,  the  point  of  a  lead  pencil, 
half-eaten  apples,  chewing  gum,  candy,  etc., 
which  others  have  handled.  In  turning  the 
leaves  of  books  or  handling  money  or  papers, 
the  finger  or  thumb  should  not  be  moistened 
with  saliva.  Drinking  from  a  cup  or  glass 
used  by  another  should  be  avoided,  unless  the 
vessel  has  been  first  thoroughly  cleaned. 
Kissing  may  carry  infection,  and  one  should 
not  kiss  a  consumptive.  In  desk  work  in 
school  or  office,  avoid  a  bent  position, — let 
the  lungs  have  full  play. 

190 


ITS    PREVENTION 

A  Clean  House  and  Dust 

Live  in  a  clean  house  accessible  to  the  en- 
trance of  air  and  light,  preferably  in  the 
suburbs.  Twice  a  year  the  house  should  be 
thoroughly  cleaned.  In  dusting  use  a  moist 
cloth  or,  when  possible,  remove  the  dust  by 
the  vacuum  system.  Dust  is  dirt  in  tiny  un- 
seen particles  in  the  air,  and  contains  among 
other  things  various  kinds  of  germs,  some 
of  which  may  be  infectious.  Dust  is  always 
a  possible  danger,  and  should  be  scrupulously 
avoided,  as  well  as  disorder,  dampness,  dark- 
ness and  bad  air.  Plain,  durable  clothing 
should  be  worn,  just  thick  enough  to  keep 
one  comfortable,  and  if  the  clothing  or  shoes 
become  wet,  they  should  be  immediately 
changed.  In  moving  into  a  house  in  which  a 
tuberculous  person  has  recently  lived,  one 
must  be  sure  that  it  has  first  been  properly 
disinfected.  This  is  of  great  importance  in 
occupying  a  cottage  in  a  health  resort. 

Spitting  and  Cuspidors 

Of  course  everyone  should  avoid  indiscrim- 
inate spitting  himself  and  shun  all  places 
where  it  is  permitted,  and,  further,  he  should 
try  in  every  way  to  persuade  others  from  in- 
dulging in  the  habit.     It  is  an  evident  hard- 

191 


TUBERCULOSIS 

ship,  however,  to  prohibit  all  spitting,  and 
when  in  the  right  place  it  is  often  a  cleanly 
thing  to  do,  as  when  one  has  a  cold  in  the 
head,  or,  from  other  causes,  has  some  un- 
cleanly discharge  in  his  mouth;  but  it  should 
be  done  in  the  right  place,  in  spittoons  pro- 
vided for  the  purpose,  partially  filled  with 
water,  and  which  are  cleansed  at  short  inter- 
vals, preferably  by  boiling.  By  a  law  of 
Massachusetts,  suitable  receptacles  for  expec- 
toration are  required  in  all  factories  and  work- 
shops, the  form  and  number  of  which  to  be 
decided  by  the  board  of  health  of  the  city  or 
town  in  which  the  factory  is  situated. 

We  cannot  yet  destroy  all  the  tubercle 
bacilli,  but  we  can  so  strengthen  and  harden 
the  body  that  it  will  be  difficult  for  the  germs, 
even  if  they  do  get  in,  to  do  harm. 

"  The  struggle  against  tuberculosis,"  says 
M.  Casimir  Perier,  "  is  intimately  bound  up 
with  the  solution  of  the  most  complex  eco- 
nomic problems,  and  any  plan  will  be  imper- 
fect which  has  not  for  its  foundation  the  ma- 
terial and  moral  improvement  of  the  people/* 


192 


XL  THE  GREAT  CRUSADE  AGAINST 
TUBERCULOSIS 

X^^^^^HERE  are  two  profoundly  im- 
M  (T"^  pressive  movements  taking  place 
K  J  in    the    world    to-day,    both    of 

^^^^^^  which,  although  in  a  very  differ- 
ent way,  have  for  their  ultimate 
object  the  preservation  of  human  life.  The 
one  is  the  great  Peace  movement,  whose  object 
is  the  abolition  of  war  between  nations  and 
the  settling  of  their  disputes  by  arbitration; 
the  other  is  the  present  world-wide  Crusade 
against  tuberculosis.  Of  the  extent  and 
earnestness  of  this  latter  movement,  the  re- 
cent great  International  Congress  of  Tuber- 
culosis in  Washington  (1908)  is  a  witness. 

Organized  Effort  Almost  Universal 

In  almost  every  civilized  country  of  the 
world  organized  effort  is  now  being  made  for 
the  purpose  of  fighting  tuberculosis.  While 
the  general  methods  are  and  must  be  the  same, 
each   nation   modifies  them  according  to  its 

193 


TUBERCULOSIS 

own  peculiar  conditions,  and  its  conception 
of  what  are  the  most  important  lines  of  at- 
tack. 

International   Congresses 

At  certain  intervals  representatives  of  all 
the  nations  come  together  in  a  great  interna- 
tional congress  such  as  the  one  just  referred 
to  in  Washington,  where  they  compare  the 
methods  and  results  of  the  work  in  their  re- 
spective countries,  learn  new  facts  regarding 
tuberculosis  and  new  ways  of  fighting  it,  and 
inspire  one  another  to  increased  effort.  The 
last  such  congress  was  held  in  Rome  in  1912 
and  the  next  one  will  be  in  London. 

The  Movement  Simultaneous  Among  All 
Peoples 

Such  national  and  international  action 
against  tuberculosis  is  called  the  "  Crusade," 
the  "  Warfare,"  and  ''  Struggle "  against 
tuberculosis.  All  classes  of  people,  from 
the  king  to  his  humblest  subject,  and 
from  the  president  to  the  laborer,  are  en- 
gaged in  this  Crusade.  It  is  a  fact  of  strik- 
ing significance  that  the  peoples  of  the 
world  should  thus  simultaneously  set  them- 
selves to  work  to  free  themselves  from  this 

194 


ITS    PREVENTION 

inveterate  foe  which  for  untold  years  has 
been  preying  upon  the  flower  of  their  youth 
and  manhood.  The  inspiration  of  this  Cru- 
sade arose  from  Prof.  Koch's  great  discov- 
ery of  the  cause  of  tuberculosis.  Then  and 
not  until  then  could  intelligent  action  be  taken. 
The  Crusade  began  at  first  slowly,  but  as  time 
went  on  and  the  possibility  of  the  prevention 
and  cure  of  the  disease  became  more  fully 
realized,  the  movement  began  to  grow  in  ex- 
tent and  force  until  at  present,  as  we  have 
said,  it  has  become  world-wide. 

Why  a  Crusade  Against  a  Single  Disease? 

Perhaps  one  may  ask  why  such  a  crusade 
against  a  single  disease?  Other  diseases  are 
very  prevalent,  such  as  heart,  or  kidney  dis- 
ease, rheumatism,  and,  more  frequent  than 
all,  as  we  have  seen,  pneumonia.  There  are 
several  reasons  for  this.  In  the  first  place, 
there  is  no  other  disease  which  so  habitually 
cuts  down  its  victims  in  the  best  years  of 
their  life.  Many  diseases  only  occur  in  later 
life,  and  are  called  degenerative  diseases, 
caused  by  worn-out  organs.  Pneumonia,  as 
has  already  been  said,  is  most  prevalent  and 
fatal  at  the  two  extremes  of  life, — before 
one's  work  is  begun  and  when   it  is  done. 

195 


TUBERCULOSIS 

Again,  tuberculosis  is  a  contagious  or  com- 
municable disease,  the  cause  of  which  we 
know,  as  well  as  its  prevention.  We  know 
how  to  avoid  it,  to  prevent  it,  to  cure  it. 
Finally,  it  has  a  steady,  continuous  preva- 
lence without  intermission.  Many  contagious 
diseases  come  in  epidemics  and  then  cease; 
tuberculosis  never  ceases. 

Principal  Forms  of  Activity 

The  principal  forms  of  activity  in  the  cam- 
paign against  tuberculosis  consist  in: 

(i)  Educational  propaganda. 

(2)  Sanatoria. 

(3)  Tuberculosis  dispensaries. 

(4)  Tuberculosis  hospitals  for  advanced 
cases. 

(5)  Laws  and  regulations  regarding  noti- 
fication, disinfection,  indiscriminate  expectora- 
tion, isolation  of  advanced  cases. 

(6)  The  founding  of  tuberculosis  associa- 
tions and  leagues. 

(7)  The  prevention  of  tuberculosis  in  chil- 
dren and  care  of  tuberculosis  children. 

(8)  General  improvement  of  the  hygienic 
and  living  conditions  of  the  poor  in  cities  by 
improved  dwellings,  etc. 

196 


THE   GREAT   CRUSADE 

(9)  Inspection  of  factories  and  workshops 
and  improvement  of  sanitary  conditions  of 
the  same. 

(10)  Supervision  of  the  milk  supply. 
Germany 

Germany  took  the  lead  in  this  warfare,  and 
it  was  quite  natural  that  it  should  do  so,  for 
Prof.  Koch,  who  made  it  possible,  was  him- 
self a  German.  The  lines  of  effort  in  Ger- 
many are  various  and  include  both  the  direct 
and  indirect  attack.  Their  main  effort  is, 
perhaps,  in  the  line  of  the  direct  attack,  the 
cure  of  the  curable  cases,  and  the  protection 
of  the  well,  particularly  the  latter.  No  coun- 
try possesses  so  many  sanatoria,  both  pub- 
lic and  private,  as  does  Germany.  There  are 
considerably  over  100  such  institutions  with 
10,000  or  more  beds,  and  about  40,000  in- 
dividuals are  treated  every  year  in  them. 
Some  have  been  established,  and  they  are 
among  the  best  and  largest,  by  the  National 
Insurance  Societies,  who  insure  all  workmen 
against  disease.  Others  have  been  erected 
by  cities,  communities,  the  Red  Cross  Society, 
corporations  and  private  individuals.  About 
65  per  cent,  of  the  patients  treated  in  these 
sanatoria  become  fully  caoable  of  resuming 

197 


TUBERCULOSIS 

their  former  work,  an  "economic  cure,"  as 
it  is  called.  To  treat  its  consumptive  work- 
ingmen  in  sanatoria  in  the  early  stage  of  their 
disease,  and  discharge  them  in  a  condition 
to  resume  their  work,  was  found  to  be  far 
more  economical  than  to  care  for  them  through 
a  lingering  illness. 

Compulsory  Insurance  of  Workingmen 

One  of  the  most  admirable  institutions  in 
Germany,  which  has  done  more  than  all  other 
means  in  this  struggle  against  tuberculosis, 
is  the  compulsory  insurance  of  workingmen. 
Every  workingman  (one- fourth  of  the  popu- 
lation of  Germany)  is  compelled  by  imperial 
law  to  be  insured  against  sickness,  accident 
and  invalidity.  Each  insurance  company  se- 
cures for  the  laboring  man,  in  case  he  is  per- 
manently disabled  by  sickness  or  accident, 
an  allowance  for  life.  For  this  purpose  the 
employer  as  well  as  the  employee  are  re- 
quired to  contribute  their  share  in  equal  parts : 
the  highest  amount  the  latter — the  working- 
man — contributes  is  six  cents  a  week.  The 
most  important  thing  for  the  workingman  as 
well  as  for  the  insurance  company  is  to  be 
able  to  work  and  to  maintain  this  working 

198 


THE   GREAT   CRUSADE 

ability  as  long  as  possible.  Hence  one  of  the 
principal  objects  of  the  insurance  companies 
is  to  prolong  the  working  period.  Just  as 
soon,  therefore,  as  tuberculosis  is  discovered 
in  a  workingman,  he  is  at  once  placed  under 
treatment  in  one  of  the  well-equipped  sana- 
toria constructed  by  the  insurance  companies, 
where  he  is  treated  free  of  cost  for  an  in- 
definite period.  During  the  time  that  he  is 
under  treatment  his  wife  and  children  are 
supported  in  every  way  by  the  company.  The 
same  companies  also  maintain  dispensaries 
and  day  camps  for  the  workingman  and  pro- 
vide him  with  dental  attention  free  of  cost. 
All  this  is  done,  not  out  of  philanthropy,  but 
from  a  purely  economic  basis.  The  insur- 
ance companies  have  found  it  cheaper,  as  we 
have  said,  to  treat  and  cure  the  tuberculous 
workingman  and  get  him  back  to  work  and 
off  their  hands  than  to  support  him  and  his 
family  during  a  much  longer  period  of  illness, 
if  the  disease  is  allowed  to  run  on  without 
timely  treatment.  How  difficult  it  is  to  make 
communities  realize  this  proved  economic  fact ! 
They  allow  the  poor  consumptive  to  run  on 
into  a  hopeless  condition,  and  then  they  have 
to  take  care  of  him  at  public  expense  as  long 

199 


TUBERCULOSIS 

as  he  lives,  and  at  the  same  time  care  for  his 
family.  How  much  cheaper  it  would  be  to 
treat  the  consumptive  at  the  right  time,  and 
in  the  right  place,  until  he  was  well. 

These  German  insurance  companies  for 
working  people  have  at  present  a  capital  of 
five  hundred  millions  of  dollars,  and  irl  1907 
the  German  Workingman's  Insurance  Com- 
pany had  expended  for  the  tuberculosis  cam- 
paign $3,000,000.  A  further  extension  of 
this  compulsory  insurance  is  already  deter- 
mined upon,  namely,  the  care  of  widows  and 
orphans  of  workingmen. 

There  are  some  things  that  an  enlightened 
monarchical  form  of  government  can  do  for 
its  subjects  better  than  the  people  in  a  demo- 
cratic form  of  government  can  or  will  do  for 
themselves,  and,  evidently,  the  compulsory 
insurance  for  workingmen  would  seem  to  be 
one. 
Information  Bureaus 

In  Berlin  there  have  been  established  "  In- 
formation Bureaus,"  as  they  are  called,  whose 
purpose  it  is  to  prevent  the  spread  of  pul- 
monary tuberculosis.  At  these  bureaus,  any 
one  who  desires  it  can  have  his  lungs  exam- 

200 


THE    GREAT   CRUSADE 

ined  free  of  charge,  and  if  tuberculosis  is 
discovered,  he  is  instructed  as  to  the  neces- 
sary measures  to  be  taken  to  prevent  the  in- 
fection of  others,  and  is  cared  for  as  his  cir- 
cumstances require.  All  the  members  of  his 
family  are  required  to  present  themselves  for 
examination.  The  patient's  home  and  family 
are  kept  under  constant  supervision,  and 
proper  sanitation  is  secured  and  the  inmates 
trained  to  live  hygienically.  The  striking  fea- 
ture of  these  bureaus  is  the  constant  watch 
maintained  over  the  home  and  family  of  the 
consumptive,  to  prevent  the  spread  of  the 
disease  from  the  sick  member  to  others  of 
his  family. 

Other  Forms  of  Tuberculosis  Work  in  Germany 
The  Germans  have  also  developed  many 
other  forms  of  tuberculosis  work,  such  as 
the  park  convalescent  or  day  camps ;  forest 
schools  for  tuberculous  children  in  the  vi- 
cinity of  large  cities;  vacation  settlements; 
farm  colonies  for  patients  discharged  from 
the  sanatorium ;  sea-side  hospitals  for  children 
with  bone,  joint  or  gland  tuberculosis.  In 
Berlin  and  elsewhere  model,  clean,  well-ven- 

201 


TUBERCULOSIS 

tilated  tenements  have  been  erected  in  in- 
creasing numbers,  and  for  this  purpose  large 
sums  have  been  loaned  by  the  state  and  the 
workingmen's  insurance  institutions.  Besides 
the  above  special  kinds  of  effort,  there  are 
also  the  various  measures  common  to  other 
countries,  such  as  restriction  of  spitting,  dis- 
infection, compulsory  notification,  etc.  It  is 
said  that  Berlin  has  the  best  control  of  the 
tuberculosis  situation  of  any  city  in  Europe 
comparable  to  Boston  and  New  York  City  in 
this  country. 
England 

England  comes  next  to  Germany  of  Euro- 
pean countries  in  its  activity  in  the  tubercu- 
losis Crusade.  Long  before  Koch's  discov- 
ery, consumptive  hospitals  existed  in  London. 
The  largest  of  them,  the  Brompton  Hospital, 
was  established  in  1841,  and  its  foundation 
happened  in  an  interesting  way :  A  consump- 
tive clerk  of  Sir  Philip  Rose  was  rejected  at 
several  general  hospitals,  and  learning  of  the 
fact,  certain  philanthropists  determined  to 
erect  a  special  consumptive  hospital ;  and  the 
result  was  the  great  Brompton  Hospital  with 
between  three  hundred  and  four  hundred  beds. 
It  is  doubtless  partly  due  at  least  to  its  con- 
sumptive hospitals  that  the  death  rate  from 

202 


THE    GREAT   CRUSADE 

this  disease  is  so  low  in  London,  one  of  the 
lowest  in  any  large  city,  less  than  half  that 
in  Paris  and  Vienna. 

There  are  also  many  sanatoria  in  England. 
One  of  the  newest  is  the  King  Edward  VII 
Sanatorium,  costing  $1,000,000,  the  gift  of 
one  man.  There  is  a  national  association  for 
the  prevention  of  tuberculosis  and  many  simi- 
lar  local  associations.  In  1901  a  great  In- 
ternational Congress  on  Tuberculosis  was  held 
in  London.  In  Edinburgh  Dr.  Philip  estab- 
lished the  well-known  Victoria  Dispensary  in 
i887,  one  of  the  first  and  best  of  the  kind  in 
the  world.  In  some  English  towns  consump- 
tives are  received  for  temporary  residence  in 
isolation  hospitals  for  educational  purposes,  in 
order  that  they  may  learn  how  best  to  live 
wholesome  lives  and  how  to  deal  with  their 
sputum.  The  city  of  Birmingham  was  the 
first  city  to  erect  a  municipal  sanatorium  for 
its  consumptive  sick;  and  it  is  interesting  to 
recall  the  fact  that  near  this  city,  sixty  years 
ago,  George  Bodington  erected  his  sanatorium 
for  the  open-air  treatment  of  tuberculosis  and 
received  such  opposition  that  he  was  obliged 
to  abandon  the  scheme.  The  new  sanatorium 
surely  ought  to  be  dedicated  to  his  memory. 

England  is  also  doing  much  in  an  indirect 
way  in  the  prevention  of  tuberculosis  by  its 

203 


TUBERCULOSIS 

excellent  sanitary  service,  model  tenements, 
better  and  cheaper  food,  decrease  of  alcohol- 
ism, and  a  general  diminution  of  pauperism, 
all  of  which  has  played  an  important  part  in 
the  steady  decline  of  the  death  rate  from 
tuberculosis  which  has  been  going  on  in  Eng- 
land for  many  years.  The  English  govern- 
ment has  now  established  the  "  National 
Insurance  Act "  similar  to  the  German  *'  Com- 
pulsory Insurance  law,"  and  provided  a  capi- 
tal sum  of  $7,500,000  for  the  erection  of 
sanatoria  for  the  entire  community. 

Ireland 

In  1907  the  Women's  National  Health  As- 
sociation of  Ireland,  under  the  leadership  of 
the  Countess  of  Aberdeen,  inaugurated  an 
aggressive  campaign  against  tuberculosis, 
which  is  far  more  prevalent  in  that  country 
than  in  England.  If  the  death  rate  from  tu- 
berculosis in  Ireland  was  reduced  to  that  in 
England,  it  would  mean  the  annual  saving 
of  4,000  lives  in  the  former  country.  By 
means  of  a  traveling  tuberculosis  exhibition, 
accompanied  by  lectures  upon  the  subject, 
public  enthusiasm  was  aroused  throughout  the 
land.  "  Everywhere,"  says  the  report  upon 
the  movement,  "  the  talk  is  of  tuberculosis, 
fresh  air,  open  windows ;  and  the  virtues  of 

204 


THE    GREAT    CRUSADE 

the  same  are  being  discussed  with  vehemence 
in  the  clubs  and  pubHc  houses."  In  one  place 
visited  by  the  exhibition  and  the  Countess,  a 
number  of  people  in  the  poor  streets  decided 
to  show  their  welcome  of  the  Countess  by 
whitewashing  their  houses  inside  and  out. 
"  The  bishops  and  clergy  of  all  denomina- 
tions, the  landlords  and  tenants,  the  town  and 
city  officials,  the  town's  people  and  the  peas- 
ants, were  all  united  in  the  desire  to  stamp 
out  tuberculosis.  In  1908  the  Tuberculosis 
Prevention  Act  was  passed,  which  gives 
power  to  county  councils  to  establish  sana- 
toria and  dispensaries.  In  191 2  there  were 
17,000  fewer  people  suffering  from  tuber- 
culosis in  Ireland  than  there  were  in 
1907. 

France 

In  France,  where  there  is  a  high  mortality 
from  tuberculosis  there  are  comparatively  few 
sanatoria  for  adults,  but  the  main  effort  is 
directed  to  the  prevention  and  treatment  of 
tuberculosis  in  children.  The  authorities  in 
this  coimtry  consider  that  the  infection  gen- 
erally takes  place  in  childhood,  and,  therefore, 
the  chief  attention  should  be  directed  to  pre- 
venting tuberculosis  in  the  child,  when  it  is 
exposed  to  the  contagion  in  the  home  where 

205 


TUBERCULOSIS 

some  member  is  suffering  from  the  disease. 
There  are  probably  more  sanatoria  for  chil- 
dren in  France  than  in  all  the  other  countries 
combined,  and  some  of  the  largest  and  most 
famous  sea-side  sanatoria  for  children  are 
situated  in  this  country ;  and  in  all  of  them — 
twenty-four  in  number, — there  are  accommo- 
dations for  about  4,000  children. 

Further  consideration  of  this  work  of  the 
French  with  tuberculous  children  will  be 
given  in  the  chapter  upon  "  Tuberculosis  and 
the  Child." 

The  system  of  dispensaries  is  very  exten- 
sive in  France,  and  at  Lille  Dr.  Calmette 
established  one  of  the  first  model  dispensaries 
in  Europe,  which  he  called  a  "  Preventorium," 
and  which  has  become  famous  throughout  the 
world.  There  are  many  anti-tuberculosis 
leagues  throughout  France,  united  in  a  na- 
tional federation  under  the  patronage  of  the 
president  of  the  republic.  In  1905  an  Inter- 
national Tuberculosis  Congress  was  held  in 
Paris,  under  the  auspices  of  the  government. 
Instruction  is  also  given  in  the  schools  re- 
garding tuberculosis. 

Sweden 

In  Sweden,  which  has  a  yearly  mortality  of 
about  10,000,  there  is  a  national  tuberculosis 

206 


THE    GREAT   CRUSADE 

association,  which  carries  on  an  educational 
propaganda  by  lectures,  pubHcations  and  a 
tuberculosis  museum  at  Stockholm.  It  is  in- 
teresting to  learn  that  the  chief  source  of  in- 
come of  this  association  is  through  the  pop- 
ular method  of  selling  charity  stamps,  similar 
to  the  Red  Cross  stamps ;  and  during  the 
years  1905  to  1907  the  amount  obtained  in 
this  way  was  about  $60,000. 

Sanatoria  have  been  established  both  by  the 
general  and  local  governments;  and  the  for- 
mer has  appropriated  $3,000,000  and  land  for 
the  next  ten  years  for  this  purpose.  In  1895, 
at  the  Twenty-fifth  Jubilee  of  the  reign  of 
King  Oscar  II,  the  national  collection  made 
to  commemorate  the  event,  amounting  to  over 
half  a  million  dollars,  was  donated  by  him  for 
the  erection  of  public  sanatoria,  and  this  sum, 
together  with  a  quarter  million  more  voted 
by  Parliament,  was  applied  to  the  erection 
and  maintenance  of  sanatoria  in  different 
parts  of  the  kingdom.  Dispensaries  have  also 
been  established  where  milk  and  other  food 
are  distributed  to  needy  consumptives. 

An  interesting  experiment  has  been  inaug- 
urated in  this  country  of  establishing  a  house 
with  a  number  of  tenements,  hygienically 
clean  and  wholesome,  for  families  in  which 
the  father  or  mother,  or  both,  were  suffering 

20y 


TUBERCULOSIS 

from  tuberculosis  but  still  able  to  work,  the 
children  being  healthy.  Such  a  house  has  a 
resident  nurse,  who  pays  a  daily  visit  to  every 
family  and  instructs  them  as  to  cleaning,  ven- 
tilation, the  proper  care  of  the  sputum,  etc. 
Everything,  though  very  simple,  is  kept  hy- 
gienically  clean.  A  somewhat  similar  experi- 
ment is  now  being  carried  out  in  the  Vander- 
bilt  East  River  Homes  in  New  York  City.  A 
very  important  work  is  also  being  done  with 
healthy  children  of  consumptive  parents. 
With  the  consent  of  the  latter,  the  children 
are  removed  from  their  homes  and  the  chances 
of  infection,  and  boarded  out  in  temporary 
homes  or  institutions.  The  public  press  of 
Sweden  has  also  been  very  helpful  in  the  tu- 
berculosis Crusade. 

Denmark 

In  the  little  country  of  Denmark,  with  a 
population  of  a  little  over  two  and  a  half  mil- 
lions, there  is  a  national  association  which 
maintains  five  sanatoria  for  the  poor,  and  a 
dispensary  at  Copenhagen.  This  association 
is  also  very  active  in  the  educational  propa- 
ganda, disseminating  literature  and  provid- 
ing lectures  for  the  public  and  for  school 
children.  It  was  also  aided  in  the  erection 
of  other  sanatoria  in  out-of-the-way  islands, 

208 


THE    VANDERBILT    EAST    RIVER    HOMES. 


THE    GREAT    CRUSADE 

as  in  the  Faroe  Islands,  where  there  is  a  com- 
bined hospital  and  sanatorium. 

The  state  and  various  societies  maintain 
other  sanatoria,  consumptive  hospitals,  and 
sea-side  hospitals  and  sanatoria  for  children, 
affording,  in  all,  accommodations  for  2,180 
patients  of  the  poorer  classes,  so  that  anyone 
who  desires  can  obtain  admission  in  some  of 
these  institutions.  Among  the  public  meas- 
ures for  combating  tuberculosis  are  compul- 
sory notification,  compulsory  disinfection  af- 
ter death  from  tuberculosis,  prohibition  of 
spitting,  and  the  prohibiting  of  women  suf- 
fering from  tuberculosis  from  becoming  wet 
nurses.  Tuberculous  children  are  prohibited 
from  attending  school  and  tuberculous  teach- 
ers from  teaching  school.  Before  children  be- 
gin to  work  in  workshops  or  factories,  a  doc- 
tor's certificate  must  be  produced,  stating  that 
they  do  not  suffer  from  tuberculosis.  Chil- 
dren living  under  such  conditions  in  their 
homes  as  are  injurious  to  their  health,  may 
be  taken  away  from  the  parents  and  boarded 
out  in  good  homes.  No  person  suffering 
from  tuberculosis  of  the  lungs  and  throat  is 
allowed  to  fill  an  office  in  the  civil  service  that 
would  bring  him  in  close  contact  with  the 
people.  Another  excellent  provision  requires 
that  the  floor  of  school  rooms  shall  be  washed 

209 


TUBERCULOSIS 

at  least  twice  a  month,  and  that  the  floor  as 
well  as  the  desks,  etc.,  shall  be  wiped  with  a 
wet  cloth  every  day  after  school  hours  while 
the  premises  are  being  aired. 

Switzerland 

In  Switzerland  whose  yearly  mortality  from 
tuberculosis  is  9,000,  there  are  many  so-called 
high-altitude  resorts  for  tuberculosis  which  are 
visited  by  consumptives  from  various  portions 
of  Europe.    Davos  is  best  known  and  contains 
several  sanatoria.    Leysin,  St.  Moritz,  Ander- 
matt  and  Arosa  are  of  similar  climatic  char- 
acteristics.    There  are  a  number  of  popular 
and  private  sanatoria  with  accommodation  in 
all  for  1,600  patients,  and,  in  addition,  several 
institutions  for  tuberculous  children,  and  what 
are  called  holiday  colonies   for  children  and 
farm    colonies    for    convalescent   adults.     As 
with  the  other  countries,  there  are  many  tuber- 
culosis associations  in  Switzerland,  and  in  the 
canton  of  Bern  the  Grand  Council  has  adopted 
extensive  provision  for  the  educational  propa- 
ganda and  the  prevention  of  tuberculosis.    Al- 
coholism is  given  as  the  most  common  pre- 
disposing cause  of  the  disease  in  this  country. 
It  seems   strange   that   a   land  like   Switzer- 
land, with  such  pure  mountain  air,  should  suf- 

210 


THE    GREAT   CRUSADE 

fer  very  much  from  tuberculosis,  but  here 
again  the  in-door  Hfe,  fostered  by  the  long, 
cold  winter,  is  probably  a  powerful  contribu- 
ting cause,  together  with  alcoholism,  just  men- 
tioned. 

Belgium 

Belgium  has  a  large  and  active  National 
League  against  tuberculosis  with  over  6,000 
members.  It  has  established  dispensaries, 
cares  for  consumptives,  and  expends  in  this 
work  more  than  $50,000  annually.  The  dis- 
pensary system  is  elaborately  developed  in 
Belgium,  after  the  plan  of  Calmette  in  France, 
and  the  name  "  Preventorium,"  which  he 
originated,  is  applied  to  them.  Sanatoria 
have  also  been  established,  the  one  in  the 
province  of  Liege  costing  $240,000.  The 
campaign  against  tuberculosis  in  the  Belgian 
army  has  been  vigorously  pushed  and  strict 
measures  have  been  adopted  with  regard  to 
it.  In  the  rooms  of  all  military  establish- 
ments are  placards  with  the  following  in- 
scriptions :  "  Do  not  spit  on  the  floor :  it  is 
dirty  and  dangerous,  as  the  tuberculous 
sputum,  dried  and  reduced  to  dust,  is  the 
means    of    spreading    consumption."      Large 

211 


TUBERCULOSIS 

sums  of  money  have  been  spent  in  the  build- 
ing and  improvement  of  barracks,  schools  and 
hospitals. 

Norway 

Norway  was  the  first  country  to  pass  laws 
requiring  compulsory  notification  of  tubercu- 
losis, disinfection  after  death,  or  change  of 
residence,  and  removal  to  a  hospital  if  hy- 
gienic instruction  were  not  carried  out.  So- 
called  Nursing  Homes  were  first  established 
in  this  country,  primarily  for  the  purpose  of 
isolating  advanced  and  incurable  cases.  These 
homes,  containing  six  to  ten  beds,  are  in 
charge  of  a  nurse,  and  are  plainly  but  com- 
fortably constructed,  and  maintained  at  a 
small  cost.  As  it  is  well  known,  leprosy  has 
existed  in  Norway  for  centuries,  but  is  now 
nearly  extinct,  owing  to  its  being  isolated. 
Funds  devoted  to  this  purpose  ever  since  the 
Middle  Ages  have  now  been  diverted  to  the 
care  of  tuberculous  persons,  and  a  leper  hos- 
pital, no  longer  needed  for  its  original  purpose, 
has  been  changed  to  a  sanatorium.  May  this 
same  thing  happen  with  regard  to  tubercu- 
losis, and  when  that  becomes  extinct,  the  sana- 
toria converted  to  other  uses.     There  are  a 

212 


THE   GREAT   CRUSADE 

number  of  private  sanatoria  in  Norway,  and 
two  marine  ones  for  the  treatment  of  surgi- 
cal tuberculosis  in  children. 

In  the  city  of  Bergen,  where  the  Crusade 
has  been  energetically  carried  on,  the  mortality 
from  tuberculosis  has  decreased  about  50  per 
cent,  within  the  kst  eleven  years.  It  is  a 
notable  fact  that  the  decrease  is  greatest  in  the 
cities. 

Tuberculosis  Work  in  Other  Countries 

In  similar  ways  the  great  Crusade  is  in 
progress  in  Russia,  Italy,  Spain,  Portugal, 
Roumania,  Bulgaria,  Bohemia,  Turkey  and 
Greece.  Both  the  governments  and  the  peo- 
ple are  united  in  this  great  movement.  By 
the  invitation  of  the  King  of  Italy  the  last 
International  Tuberculosis  Congress  was  held 
in  Rome  in  1912. 

On  the  other  side  of  the  globe,  Japan,  Aus- 
tralia and  New  Zealand  are  actively  engaged 
in  this  cause.  On  this  side  of  the  water  many 
of  the  South  America  states,  Mexico  and 
Central  America,  have  their  anti-tuberculosis 
leagues,  and  have  established  dispensaries  and 
sanatoria.  Indeed,  at  the  present  time  one 
could  almost  estimate  the  degree  of  civiliza- 

213 


TUBERCULOSIS 

tion  of  any  country  by  the  degree  of  its  ac- 
tivity in  the  great  Crusade  against  tubercu- 
losis. 

Canada  and  Brehmer  Rest 

In  Canada,  besides  its  tuberculosis  associa- 
tion with  its  various  affiliations  and  its  pub- 
lic and  private  sanatoria,  there  is  a  most 
valuable  and  interesting  institution  at  St. 
Agathe-des-Monts,  in  the  Laurentian  Moun- 
tains, called  "  Brehmer  Rest,"  or  the  "  Pre- 
ventorium," v^here  young  workingwomen 
who  do  not  have  tuberculosis,  but  seem  pre- 
disposed to  it,  such  as  convalescents  from 
various  acute  diseases,  shop  girls,  factory 
workers,  typewriters,  etc.,  are  received  and 
by  rest,  good  food,  and  fresh  air,  restored 
to  their  normal  health  and  resisting  power 
and  thus  rescued  from  the  possibility  and, 
with  many,  the  probability  of  developing 
active  tuberculosis,  thus  admirably  illustrat- 
ing the  fact  that  the  best  time  to  treat  a  dis- 
ease is  before  it  begins ;  and  in  weeks  doing 
what  later  it  would  take  months  to  accom- 
plish, when  active  tuberculosis  begins.  If, 
as  has  been  asserted  by  a  good  authority, 
from  50  to  90  per  cent,  of  us  all  have  had 
tuberculosis    at    some    time,    or    will    have 

214 


THE    GREAT    CRUSADE 

it  before  we  die,  though  it  may  never  be- 
come active,  then  the  value  of  such  a  '*  Pre- 
ventorium "  is  evident,  for  many  of  its  in- 
mates undoubtedly  would,  if  left  to  go  on  in 
their  depressed  vital  condition,  develop  active 
disease.  The  best  means  to  avoid  tuberculosis 
is  to  always  keep  one's  self  in  a  sound  state 
of  health,  and,  consequently,  in  a  state  of  re- 
sistance to  the  tubercle  bacilli;  and  when,  for 
one  reason  or  another,  one's  vitality  gets  low, 
the  danger  threatens,  and  this  unique  institu- 
tion, the  "  Preventorium,"  is  the  helping  hand 
which  aids  in  warding  it  off. 

The   Tuberculosis   Crusade   in  the   United 
States 

In  the  United  States  we  find  that  the  ratio 
of  tuberculosis  per  i,ooo  of  the  population  is 
about  that  in  England,  and  yet  the  campaign 
against  the  disease  in  the  past  has  not  been 
as  active  in  this  country  as  in  the  latter. 
Now,  however,  for  several  years  past  the 
country  has  been  awakening,  and  increased 
effort  is  being  made.  The  International 
Congress  at  Washington  has  undoubtedly 
had  its  influence  in  stimulating  the  states 
and    people    to    greater    activity.     We    have 

215 


TUBERCULOSIS 

as  yet,  unfortunately,  no  National  Bureau  of 
Health,  as  in  Germany,  to  lead  in  such  great 
movements  as  this  one  against  tuberculosis. 
Civilization  has  not  yet  arrived  at  that  stage 
when  the  protection  of  health  is  regarded  as 
paramount  to  the  protection  of  property. 
Neither  does  the  general  government  appro- 
priate any  considerable  sums  for  the  preven- 
tion of  disease  in  man,  although  it  maintains 
a  cattle  bureau  and,  presumably,  makes  a  lib- 
eral appropriation  for  this  object. 

The  Price  of  a  Battleship  for  the  Tuber- 
culosis Crusade 

If  only  the  price  of  one  battleship  could 
each  year  be  devoted  to  the  prevention  of 
tuberculosis,  how  much  could  be  accom- 
plished; and  if  half  of  what  is  now  appro- 
priated for  military  purposes  could  be  em- 
ployed against  this  one  disease,  with  what 
strides  should  we  see  it  disappear!  Since 
the  year  1908  the  amount  of  tuberculosis  ac- 
tivity in  this  country  has  been  steadily  increas- 
ing and  nearly  twenty  million  dollars  have 
been  expended  in  the  campaign  of  1913.  The 
State  of  New  York  appropriated  nearly  four 
million ;   Pennsylvania   over  a   million   and   a 

216 


THE   GREAT   CRUSADE 

half ;  Massachusetts  over  a  milHon ;  and  about 
three  millions  was  expended  by  fraternal  or- 
ganizations, labor  unions  and  insurance  com- 
panies. Since  1909  the  percentage  of  public 
money  spent  in  tuberculosis  work  has  in- 
creased from  53.5  to  nearly  70  per  cent. 
What  could  have  been  accomplished  if  $10,- 
000,000,  the  price  of  one  battleship,  had  been 
available  in  addition!  It  has  recently  been 
proposed  by  Dr.  Knopf  of  New  York  that 
the  United  States  government  should  place  at 
the  disposal  of  the  various  states  of  the  Union 
some  of  its  discarded  battleships  and  cruisers 
to  be  used  for  open-air  schools,  preventoria, 
and  sanatorium  schools  for  children,  or  hos- 
pital sanatoria  for  adults.  The  Italian  gov- 
ernment has  done  this  with  three  of  its  dis- 
carded men-of-war. 

What  the  United  States  Government  is 
Doing 

The  tuberculosis  work  in  the  United  States 
has  been  chiefly  carried  on  by  the  people, 
through  voluntary  associations,  and  by  the 
state  governments.  The  United  States  gov- 
ernment, however,  has  established  sanatoria 
for  its  soldiers  and  sailors  in  Colorado  and 
New  Mexico,  and  has  also  promulgated  rules 

217 


TUBERCULOSIS 

and  regulations  against  indiscriminate  spitting 
in  all  government  buildings,  such  as  the  post 
offices  and  various  government  departments 
in  Washington.  In  1905,  President  Roose- 
velt issued  orders  for  the  purpose  of  pre- 
venting and  eliminating  tuberculosis  among 
the  employees  in  the  public  service.  The  sani- 
tary condition  of  all  public  buildings  and 
workshops  was  to  be  inspected  and  rules  of 
prevention  were  required  to  be  displayed. 
Any  consumptive  workman  was  to  take  spe- 
cial care  not  to  infect  others,  and  those  sus- 
pected of  having  tuberculosis  were  to  be  ex- 
amined at  public  expense. 

The  National  Tuberculosis  Association 

Nine  or  ten  years  ago  a  National  Associa- 
tion for  the  study  and  prevention  of  tuber- 
culosis was  founded,  the  chief  function  of 
which  is  educational.  In  carrying  out  this 
educational  work,  the  association  has  sought 
to  interest  all  classes  of  people  to  aid  cities, 
towns,  and  states  in  organizing  tuberculosis 
associations,  in  procuring  special  legislation 
in  the  interests  of  tuberculosis  prevention  and 
care  and  in  disseminating  knowledge  regard- 
ing the  many  means  and  methods  of  fighting 
tuberculosis,  and  in  collecting  statistics  upon 

218 


THE    GREAT   CRUSADE 

the  many  phases  and  movements  of  the  tuber- 
culosis crusade.  There  are  now  in  this  coun- 
try over  twelve  hundred  tuberculosis  associa- 
tions. Sanatoria  and  dispensaries  have  also 
been  rapidly  multiplying  and  there  are  now 
527  special  tuberculosis  sanatoria  and  hos- 
pitals and  395  tuberculosis  dispensaries,  and 
their  number  is  almost  daily  increasing. 

The  Red  Cross  Stamps 

By  means  of  the  Red  Cross  stamps  or  seals, 
40,000,000  of  which  were  sold  last  Christmas, 
not  only  has  a  very  considerable  amount  of 
money  been  raised  for  the  cause,  but  they 
have  proved  one  of  the  greatest  mediums  of 
education.  These  stamps  are  widely  adver- 
tised by  colored  posters  and  cards  placed  in 
store  windows,  stations  of  the  subway  and 
elevated  roads,  and  posted  about  the  city.  On 
a  poster,  among  other  things,  was  the  follow- 
ing in  large  letters :  "  Every  stamp  means  a 
bullet  in  the  fight  against  tuberculosis."  The 
stamps  were  for  sale  in  many  of  the  leading 
department  stores,  confectionery  stores,  sta- 
tioners, etc.  In  Chicago,  the  post  ofiice  gave 
the  tuberculosis  institute  a  booth  which  was 
attended  by  a  body  of  nurses  from  the  hospi- 
tals. The  following  was  written  in  praise 
of  the  virtue  of  the  stamp: 

219 


TUBERCULOSIS 

"  I'm  the  Red  Cross  Christmas  Stamp. 

This  that  I  propose  is, 
To  summon  weahh  to  fight  for  health 

And  beat  tuberculosis, — 
Beat  the  greatest  plague  of  all, 

Oust  a  pall  of  sadness, 
Treat  despair  with  food  and  air 

And  lift  it  into  gladness." 

The  Clergy  and  Churches  and  Societies 

The  labor  unions  have  entered  into  the 
campaign  with  great  zeal  and  activity,  and 
the  churches  and  clergymen  all  over  the 
country  are  uniting  in  preaching  the  great 
Crusade.  Churches  are  forming  and  main- 
taining tuberculosis  classes,  and  clergymen 
are  preaching  sermons  on  tuberculosis.  Every 
year  a  certain  Sunday  is  designated  as  "  Tuber- 
culosis Day."  In  1912  over  60,000  churches 
gave  attention  to  this  subject  on  "  Tuberculosis 
Day."  In  the  Roman  Catholic  Church  the 
clergy  are  instructing  their  congregations 
upon  tuberculosis,  and  the  subject  is  being 
taught  in  the  parochial  schools.  Thus  a  mil- 
lion and  a  quarter  school  children  and  seven- 
teen million  Catholics  in  the  United  States 
are  being  reached.  The  Young  Men's  Chris- 
tian Association,  the  Christian  Endeavor  So- 

220 


THE    GREAT    CRUSADE 

cieties,  the  women's  clubs  and  many  civic 
and  social  societies  are  all  interested  in  the 
campaign  and  are  learning  and  preaching  the 
gospel  of  the  prevention  of  tuberculosis  and 
its  cure  by  fresh  air,  rest,  and  wholesome 
food.  Besides  its  great  educational  propa- 
ganda, the  National  Association  is  continu- 
ally investigating  the  various  problems  con- 
nected with  tuberculosis,  such  as  the  cost  and 
best  methods  of  the  construction  of  sanatoria, 
tuberculosis  among  children,  and  many  other 
problems. 

Governors  and  Legislatures 

It  is  a  significant  fact  to  notice  the  atten- 
tion now  devoted  in  the  various  states  by  gov- 
ernors and  legislatures  to  the  subject  of  tuber- 
culosis. In  1913  out  of  41  state  legislatures 
in  session,  laws  dealing  with  tuberculosis  were 
enacted  in  30  states.  In  their  messages,  gov- 
ernors urge  upon  the  legislatures  the  impor- 
tance of  taking  some  action  against  tuber- 
culosis. Said  the  Governor  of  West  Virginia 
in  a  message  to  his  legislature :  "  Preven- 
tion will,  to  an  extent,  include  the  care  of 
those  who  are  afflicted  and  who  cannot  take 
care  of  themselves,  in  order  to  guard  against 
the   danger  of   their   infecting   others.     One 

221 


TUBERCULOSIS 

consumptive  person  may  infect  hundreds  of 
others,  for  he  will  grow  and  emit  millions  of 
the  diseased  germs.  Hospitals  or  like  places 
where  such  persons  may  be  isolated  and 
treated  is  a  necessary  part  of  any  reasonably 
effective  campaign  against  the  dreaded  dis- 
ease. That  it  would  be  a  noble  charity  goes 
without  saying.  I  recommend  to  the  legisla- 
ture the  earnest  consideration  of  the  pressing 
matter  of  promoting  the  public  health,  espe- 
cially as  concerns  the  safe-guarding  of  the 
people  against  the  awful  ravages  of  consump- 
tion." "  For  every  dollar  we  spend  in  getting 
rid  of  this  scourge"  (tuberculosis),  said 
Governor  Hughes  in  a  recent  address,  "  we 
should  save  a  hundred  dollars  in  increased 
productivity  and  efficiency." 

New  York 

Of  the  individual  states,  perhaps  New 
York,  Massachusetts,  Pennsylvania  and  Wis- 
consin are  the  leaders  in  the  Crusade,  al- 
though many  others  are  closely  following 
them.  We  have  already  seen  what  New  York 
City  has  done  in  compulsory  registration,  dis- 
infection, and  in  the  provision  for  its  tuber- 
culosis inhabitants  in  sanatoria,  hospitals  and 
dispensaries.  The  first  sanatorium  in  this 
country  was   established  by   Dr.   Trudeau  in 

222 


THE    GREAT    CRUSADE 

the  Adirondacks  in  New  York  State,  and  is  a 
monument  to  his  devotion  to  the  cause.  At 
Coney  Island  is  a  sea-side  sanatorium  for 
tuberculous  children. 

Pennsylvania 

In  Pennsylvania  a  society  for  the  prevention 
of  tuberculosis  has  existed  since  1892.  In 
Philadelphia  is  the  great  Henry  Phipps  Insti- 
tute recently  erected  for  the  study,  treatment 
and  prevention  of  tuberculosis,  established  and 
maintained  by  a  gift  of  $1,000,000  by  the  phi- 
lanthropist whose  name  it  bears.  Both  a  hos- 
pital for  advanced  cases  and  a  dispensary  are 
maintained  by  this  institute  and  much  atten- 
tion is  devoted  to  the  study  of  tuberculosis 
in  all  its  phases. 

Delaware  is  the  only  state  which  has  made 
provision  for  a  state  sanatorium  for  tubercu- 
lous negroes. 

Massachusetts 

Massachusetts  erected  the  first  state  sana- 
torium in  the  country,  and  it  affords  accom- 
modations for  350  patients.  This  same  state 
has  also  established  three  other  sanatoria  for 
early  and  advanced  cases  of  tuberculosis. 
The  first  day  camp  in  the  United  States  had 
its  origin  near  Boston,  and  in  the  same  city 
one  of  the  first  hospital  schools  for  tubercu- 

221 


TUBERCULOSIS 

lous  children  was  instituted.  By  an  act  of  the 
legislature,  fifteen  state  inspectors  of  health 
were  appointed  who  are  physicians,  and  as  a 
part  of  their  duties  they  are  required  to 
"  gather  all  information  possible  concerning 
the  prevalence  of  tuberculosis  and  other  dis- 
eases dangerous  to  the  public  health  in  their 
respective  districts."  Laws  have  been  enacted 
requiring  the  establishment  of  local  hospitals 
and  dispensaries  for  tuberculosis  throughout 
the  state.  Thus  it  will  be  seen  that  the  peo- 
ple of  the  United  States  are  "  arming  from 
East  to  West "  for  the  fight  against  the 
"  Great  White  Plague." 

Scientific  Activity  in  the  Study  of  Tuber- 
culosis 

Besides  all  the  active,  practical  work  now 
in  progress  for  the  prevention  and  treatment 
of  tuberculosis,  an  immense  amount  of  study  is 
being  devoted  to  tuberculosis  and  the  m.any 
yet  unsolved  problems  in  regard  to  it.  In 
laboratories,  in  sanatoria  and  hospitals  pa- 
tient investigators  are  at  work  striving  to  gain 
more  light  upon  this  great  subject;  and  their 
investigations  are  sure  to  result  in  added  and 
new  methods  of  fighting  the  disease.  The 
late  Prof.  Koch,  with  his  band  of  assistants, 
in  his  laboratory  at  Berlin,  devoted  much  of 

224 


THE    GREAT    CRUSADE 

his  life  to  the  study  of  this  disease.  One 
might  mention  scores  of  names  of  illus- 
trious men  the  world  over,  who,  in  the  se- 
clusion of  the  laboratory  or  in  the  clinics  of 
the  sanatoria  and  hospitals,  are  investigat- 
ing tuberculosis  problems.  To  mention  a  few, 
we  have  Behring  and  Fliigge  in  Germany; 
Prof.  Landouzy  and  Calmette  in  France; 
Newsholme,  Latham  and  Ransome  in  Eng- 
land; Phillip  in  Scotland;  Trudeau,  Baldwin 
and  Theobold  Smith  in  America;  Kitasato  in 
Japan ;  Maragliano  in  Italy. 

It  was  Fliigge  of  Germany  who  first  demon- 
strated that  particles  of  sputum  thrown  out  in 
coughing  contained  the  tubercle  bacilli,  and 
Theobald  Smith  of  Boston  who  discovered  the 
difference  between  the  bacillus  of  cattle  and 
the  human  bacillus.  Trudeau  has  for  years 
been  studying  the  conditions  of  immunity  to 
tuberculosis  and  striving  to  obtain  a  sertmi  or 
some  form  of  tuberculin  which  might  produce 
an  artificial  immunity  in  man.  Much  still  re- 
mains to  be  learned  about  tuberculosis,  for 
"  Science  moves  but  slowly,  slowly  creeping  on 
from  point  to  point."  Still  we  can  only  be 
profoundly  grateful  that  we  know  enough  to 
intelligently  carry  on  the  Crusade,  for  we 
know  that  tuberculosis  is  preventable  and  cur- 
able, and  we  know  how  this  is  done. 

225 


TUBERCULOSIS 

Effect  of  the  Tuberculosis  Crusade 

This  great  Tuberculosis  Crusade  has  in- 
directly been  of  the  highest  value  in  stimulat- 
ing the  people  to  increased  effort  in  the  im- 
provement of  the  general  conditions  of  living. 
Undoubtedly  many  of  the  measures  for  pro- 
tecting and  uplifting  the  health  of  the  masses, 
such  as  the  tenement  house  reforms,  factory 
inspection,  the  provision  of  more  play  grounds, 
laws  against  child  labor,  and  many  others, 
are  largely  due  to  the  tuberculosis  campaign, 
for  it  has  been  this  Crusade  which  has  demon- 
strated to  the  world  the  inestimable  value  of 
cleanliness  and  fresh  air. 

It  is  evident  from  the  present  world-wide 
Crusade  that  there  is  a  determination  to  fight 
tuberculosis  to  the  death.  From  the  constant 
increase  of  all  the  instrumentalities  we  have 
been  considering,  it  is  apparent  that  this  great 
movement  is  daily  gaining  in  momentum  and 
power.  The  great  awakening  is  at  hand ;  and 
from  every  indication  it  seems  destined  to 
grow  and  grow  until  the  final  consummation 
is  achieved  and  the  "  Captain  of  the  men  of 
Death,"  the  Great  White  Plague,  is  exter- 
minated. 


226 


XII.  TUBERCULOSIS  AND  THE  CHILD 

VJ^^^^  HE  fight  against  tuberculosis,'' 
m  C^\  says  Prof.  Pannwitz  of  Berlin, 
^^  I     "  is  in  the  last  analysis  an  educa- 

^^^^^  tion  of  the  people  in  social  hy- 
giene, and  every  kind  of  educa- 
tion should  begin  in  childhood."  "  Whatever 
Vi^e  do  for  the  children  is  for  the  good  of 
future  generations,"  for,  as  the  poet  Words- 
vi^orth  has  so  well  expressed  it,  "the  child  is 
father  of  the  man."  It  is,  therefore,  of  the 
highest  importance  to  protect  the  child  from 
exposure  to  tuberculosis,  and  when  it  exists, 
to  afford  it  every  opportunity  for  treatment 
and  recovery. 

Of  late  years,  especial  study  has  been  de- 
voted to  tuberculosis  in  children,  for,  as  evi- 
dence has  accumulated,  it  has  been  found  that 
the  disease  is  much  more  frequent  in  child- 
hood, than  was  formerly  supposed,  and  that 
the  frequency  of  its  occurrence  increases  with 
the  age,  the  greatest  frequency  being  between 
five  and  fifteen  years  of  age;  and  during  the 

227 


TUBERCULOSIS 

first  years  of  life  it  is  markedly  more  prev- 
alent among  girls  than  boys. 

A  large  number  of  autopsies  made  upon 
children  dying  in  hospitals  shows  a  very  con- 
siderable amount  of  tuberculosis,  not  always 
tuberculosis  of  the  lungs,  but,  what  is  common 
in  children,  tuberculosis  of  the  glands  or  other 
parts  of  the  body.  In  brief,  it  may  be  said 
that  autopsy  statistics  have  shown  that  tuber- 
culous infection  is  found  in  about  40  per  cent, 
of  all  children  dying  under  fifteen  years  of 
age. 

With  the  more  accurate  and  newer  methods 
of  examination,  it  has  also  been  found  that 
tuberculosis  is  far  more  frequent  in  living 
children,  as  we  have  said,  than  was  previously 
suspected,  or  than  the  death  rate  would  in- 
dicate. Various  observers  have  found  in  the 
examination  of  school  children  that  from  29 
to  40  per  cent.,  or  more,  gave  evidence  of 
tuberculosis.  Thus,  in  Paris,  40  per  cent,  of 
school  children  examined  showed  signs  of  the 
disease ;  and  in  the  examination  of  2,295  chil- 
dren in  New  York  by  Dr.  Williams,  29  per 
cent,  showed  tuberculosis  of  the  lungs,  while 
Philip  of  Edinburgh  found  that  among  groups 
of  children  examined  in  the  various  public 
schools  of  that  city  30  per  cent,  gave  evidence 
of    tuberculosis.     Dr.    William    C.    White   of 

228 


TUBERCULOSIS    AND    THE    CHILD 

Pittsburg  states  that  90  per  cent,  of  all  school 
children  in  our  large  cities  have  tubercle  bacilli 
in  their  system  before  reaching  the  age  of  19 
years. 

Latent  tuberculosis,  that  which  is  not  active 
and  produces  no  symptoms,  has  been  demon- 
strated by  Hamburger,  a  German  authority, 
to  be  present  in  71  per  cent,  of  children  from 
7  to  10  years,  and  from  1 1  to  14  years  in  94 
per  cent. 

Many  good  authorities,  particularly  the 
French  and  some  Germans,  believe  that  most 
cases  of  tuberculosis  become  infected  in  early 
life — in  childhood,  as  the  figures  first  cited 
appear  to  show — and  that  during  this  pe- 
riod the  disease  remains  inactive  or  latent,  that 
is,  showing  no  symptoms.  When  the  child, 
however,  undergoes  the  stress  and  strain  of 
study  and  confinement  in  school,  or  in  adult 
life  enters  into  the  struggle  of  earning  a  liveli- 
hood, with  all  the  coincident  depressing  influ- 
ences upon  the  health,  the  tuberculous  infec- 
tion, before  latent,  becomes  active,  and 
tuberculosis  in  some  form  develops.  ''  The 
harvest  of  tuberculous  disease  in  mature  Ufe," 
says  Dr.  Kelynack,  ''  is  oftentimes  dependent 
on  a  tuberculous  seed-sowing  in  early  days." 
"  Tuberculosis  in  early  life,"  he  continues,  "  is 
responsible  for  many  far-reaching  disabilities, 

229 


TUBERCULOSIS 

and  not  a  few  of  life's  long-postponed  dis- 
asters." 

How  Children  Contract  Tuberculosis 

If  so  large  a  proportion  of  children  as  the 
above  evidence  indicates  have  tuberculosis  in 
some  form,  the  natural  inquiry  is,  How  did 
they  contract  it?  In  the  first  place,  children 
are  much  more  susceptible  to  infection  of  any 
kind  than  adults.  We  speak  of  the  common, 
acute,  infectious  diseases,  such  as  measles, 
whooping  cough,  scarlet  fever,  etc.,  as  chil- 
dren's diseases,  for  children  contract  them 
more  frequently  and  readily  than  adults.  The 
same  thing  is  true  with  regard  to  tuberculosis. 
Children  are  much  more  susceptible  to  it  than 
adults.  Moreover,  children  cannot  resist  un- 
hygienic conditions  of  living,  impure  air  and 
confinement  in-doors  as  well  as  their  elders. 
Added  to  this,  a  case  of  tuberculosis  in  the 
home,  and  we  have  the  conjunction  of  the 
favorable  soil  and  the  seed.  It  is  probable, 
then,  that  very  many  cases  of  tuberculosis  in 
children  arise  in  a  consumptive  home,  and  the 
fact  that  so  many  cases  of  the  disease  are  dis- 
covered in  children  from  such  homes  is  evi- 
dence of  the  truth  of  this.  Some  cases  are 
undoubtedly  contracted  from  other  school 
children  and  occasionally  from  a  tuberculous 
teacher. 

230 


TUBERCULOSIS    AND    THE    CHILD 

With  regard  to  the  channels  through  which 
the  infection  takes  place,  whether  by  inhala- 
tion— ^breathing  in  the  germs — or  through  the 
intestinal  tract  by  means  of  infected  or  con- 
taminated food,  is  still  a  question  upon  which 
there  is  a  wide  difference  of  opinion.  This 
practically  does  not  make  very  much  differ- 
ence, however,  for  the  method  of  prevention 
is  the  same,  as  we  shall  presently  see. 

Milk  Infection 

There  is  another  view  of  the  cause  of  so 
much  tuberculosis  among  children,  and  Behr- 
ing,  whom  we  have  mentioned  before,  the  great 
German  investigator  of  contagious  diseases 
and  who  discovered  the  antitoxin  of  diph- 
theria, is  the  most  ardent  supporter  of  this 
view.  It  is  that  milk  infection  is  the  cause, 
and  that  tuberculosis  of  adults,  as  he  says, 
*'  is  only  the  concluding  chord  of  the  infant's 
cradle  song."  Behring  based  this  view  upon 
his  experiments  with  animals,  in  which  he 
found  that  young  animals  were  almost  always 
infected  by  the  food.  Milk  containing  the 
bovine  bacilli  may  infect  children,  but  that  it 
frequently  does,  we  have  not  sufficient  proof, 
and  much  evidence  against  this  theory.  For 
example,  in  Japan,  where  there  are  no  cattle, 
milk  is  never  used  as  infants'  food,  but  tuber- 

231 


TUBERCULOSIS 

culosis  is  just  as  frequent  as  in  countries 
where  milk  is  used;  and  in  Constantinople, 
where  the  mothers  invariably  nurse  their  chil- 
dren, tuberculosis  is  very  prevalent.  Nansen, 
and  other  writers  upon  the  Esquimaux  in 
Greenland,  testify  to  the  great  prevalence  of 
tuberculosis  among  them,  and  here  again  the 
mothers  invariably  nurse  their  children  for  a 
long  period.  We  have  also  the  statement  of 
the  great  authority,  Koch,  that  the  cattle 
bacillus  is  different  from  the  human  bacillus, 
and  that  the  former  is  rarely  found  in  human 
beings  suffering  from  tuberculosis.  He  there- 
fore does  not  believe  that  milk  is  a  frequent 
cause  of  tuberculosis  in  children.  "  Tubercu- 
losis of  the  bones,  joints,  glands,  and  intes- 
tinal tuberculosis,  however,  so  frequent  in 
children,  is  attributed  by  many  authorities  to 
the  bovine  bacillus  carried  in  milk."  We 
should  therefore  use  every  means  to  safeguard 
the  milk  in  this  present  uncertain  state  of  our 
knowledge  upon  this  subject  by  assuring  our- 
selves that  it  comes  from  healthy  cows,  or  by 
sterilizing  it. 

House  Infection 

We  must,  then,  regard  the  chief  cause  of 
pulmonary  tuberculosis,  at  least  in  children,  as 
house  infection,  and  a  child  in  a  home  where 

232 


TUBERCULOSIS    AND    THE    CHILD 

there  is  a  case  of  tuberculosis,  particularly 
when  it  begins  to  creep  and  handle  things  and 
puts  them  in  its  mouth,  as  babies  constantly 
do,  or  breathes  infected  dust,  has  abundant  op- 
portunity to  become  infected.  The  kind  of 
tuberculosis  which  we  have  spoken  of  before 
as  "  closed  tuberculosis,"  by  which  we  mean 
that  the  tubercle  bacilli  are  not  thrown  off 
from  the  body,  and,  consequently,  no  infection 
of  others  can  take  place,  is  the  most  common 
kind  in  children.  In  this  class  can  also  be  in- 
cluded tuberculosis  of  the  bones,  glands,  hip 
disease,  scrofula,  and  intestinal  tuberculosis, 
all  of  which  are  frequent  in  children. 

From  this  fact,  that  the  "  closed  tuber- 
culosis "  is  the  most  common  form  in  children, 
we  see  the  great  advantage  of  treating  and 
curing  it  while  it  is  in  this  stage  and  non-in- 
fectious, for  thus  we  kill  two  birds  with  one 
stone :  we  save  the  child  and  avoid  the  danger 
of  communicating  the  disease  to  others  if  the 
case  was  allowed  to  go  on  and  later  become 
"  open,"  that  is,  with  tubercle  bacilli  in  the 
sputum. 

Tuberculosis  Not  Decreasing  in  Children 

While  tuberculosis  has  been  decreasing 
more  or  less  rapidly  among  adults,  it  has  not 
done  so  with  children.     Thus,  in   Germany, 

233 


TUBERCULOSIS 

while  the  mortality  rate  has  been  progressively 
decreasing  during  the  years  of  active  adult 
life,  the  same  result  has  not  occurred,  or  only 
to  a  very  small  extent,  with  children.  On  the 
contrary,  at  the  ages  of  from  five  to  ten  years 
and  from  ten  to  fifteen  years,  tuberculosis  has 
increased.  Evidently  the  modern  anti-tuber- 
culosis measures  have  been  devoted  more 
especially  to  adult  life  than  to  children;  but 
now  the  tide  seems  to  be  turning  and  children 
are  receiving  more  attention.  France,  how- 
ever, as  we  have  seen,  has  always  recognized 
the  primary  importance  of  attention  to  tuber- 
culous children  and  those  predisposed  to  the 
disease,  and  hence  the  main  efforts  in  the 
tuberculosis  crusade  in  France  have  been 
directed  to  the  care  and  cure  of  such  children. 
In  order  effectively  to  carry  out  the  tuber- 
culosis work  with  children,  we  must  begin 
with  the  mothers,  and  children  in  the  home, 
and  then  with  the  children  in  the  schools. 
Nursing  mothers  must  be  protected  and  af- 
forded time  and  opportunity  for  properly 
caring  for  their  infants  and  themselves.  In 
France  there  are  Mothers'  Help  Societies, 
which,  in  various  ways,  aid  in  securing  care 
and  rest  for  young  mothers :  and  milk  dispen- 
saries, called  "creches,"  which  consist  of  a 

234 


TUBERCULOSIS    AND    THE    CHILD 

hall  or  ward  in  a  working  district  where 
working  mothers  can  go  and  nurse  their  chil- 
dren without  interfering  with  their  work.  In 
Italy  and  Portugal  the  law  requires  the  estab- 
lishment of  such  creches  in  every  factory 
where  women  are  employed.  For  women  who 
are  unable  to  nurse  their  children,  sterilized 
or  pasteurized  milk  is  furnished  in  the  French 
creches. 

In  this  country  there  has  recently  been 
established  near  New  York,  through  the  be- 
neficent gift  of  Mr.  George  H.  F.  Schrader,  a 
home  and  school  for  mothers  called  "  Caro- 
line Rest,"  where  poor  women,  worn-out  with 
factory  work  and  household  duties,  can  go 
and  rest  after  the  birth  of  their  children.  The 
home  accommodates  thirty  mothers  and  twice 
as  many  babies  and  young  children.  There  is 
also  connected  with  this  home  a  corps  of 
"  Caroline  Rest "  nurses  who  visit  the  mothers 
in  their  homes  before  the  birth  of  their  chil- 
dren and  instruct  them  in  personal  hygiene. 
While  the  mothers  are  at  the  home,  they 
receive  instruction  in  infant  and  personal 
hygiene,  cooking,  etc. 

Children  in  Infected  Homes 

In   dealing  with   the  problem   of   children 
235 


TUBERCULOSIS 

of  tuberculous  parents  in  the  home  where  the 
surroundings  are  favorable  for  the  transmis- 
sion of  the  disease,  we  must  either  do  what 
we  can  to  protect  the  child  while  it  remains  at 
home  or  remove  it  from  its  dangerous  sur- 
roundings. That  the  danger  of  contracting 
the  disease  by  the  child  is  great  in  such 
homes  has  been  shown  by  Dr.  Sachs  of  Chi- 
cago, who  found,  in  the  examination  of  such 
children,  that  28  per  cent,  between  five  and 
ten  years  of  age,  and  25  per  cent,  between 
ten  and  fourteen,  gave  evidence  of  tubercu- 
losis. 

In  France  Prof.  Grancher  established  the 
"League  for  the  Preservation  of  Children 
from  Tuberculosis,"  the  main  object  of  which 
is  to  remove  children  of  tuberculous  parents 
from  their  homes,  where  they  are  daily  ex- 
posed to  infection,  and  to  send  them  into  the 
country.  In  his  appeal  Prof.  Grancher  said 
that  he  had  for  a  long  time  been  haunted  by 
the  leading  idea  of  Pasteur's  book  on  "  Dis- 
eases of  the  Silk  Worms,"  that  in  order  to 
save  a  race  that  is  threatened  by  an  infectious 
disease,  the  best  plan  is  to  save  the  cocoon. 
Children  taken  from  tuberculous  homes  are 
boarded  in  the  country  with  the  farmers  or 

236 


TUBERCULOSIS    AND    THE    CHILD 

rural  families,  and  in  addition  there  are  rural 
colonies  where  poor  illy-developed  children 
from  tuberculous  homes  are  afforded  a  long 
stay  in  the  country  or  by  the  sea-side;  and 
holiday  colonies  for  school  children  during 
their  vacation. 

In  Germany  there  are  also  many  vacation 
colonies  for  delicate  children,  located  either 
among  the  extensive  forests  which  surround 
many  of  the  large  German  cities,  or  in  the 
open  country,  or  on  the  sea-coast.  The  Berlin 
Society  for  Vacation  Colonies  has  assisted  in 
this  way  over  70,000  children.  In  Sweden,  as 
we  have  seen,  healthy  children  from  consump- 
tive families  have  been  removed  and  boarded 
out,  and  two  children's  homes  have  been  es- 
tabhshed,  with  fifty  beds,  where  the  children 
are  kept  until  suitable  families  are  found  with 
whom  they  can  be  placed.  In  Denmark, 
Switzerland  and,  indeed,  in  most  coun- 
tries at  the  present  time,  vacation  or  holiday 
colonies  exist  for  weak  or  sickly  children.  If 
it  were  possible  to  do  so,  the  only  sure  method 
of  safeguarding  the  children  of  tuberculous 
parents  would  be  their  removal  from  such 
homes,  and  placing  them  in  the  country  under 
wholesome  hygienic  conditions. 


TUBERCULOSIS 

A  Tuberculous  Mother  Should  Not  Nurse  Her 
Infant 

In  the  case  of  the  infant  of  a  mother  with 
active  tuberculosis,  under  no  conditions  should 
the  latter  nurse  her  child  or  have  it  with  her, 
for  the  obvious  chances  of  infection  are  great, 
not,  however,  through  the  mother's  milk,  but 
through  the  intimate  association  of  the  child 
with  its  mother.  If  removed  from  its  tuber- 
culous mother  at  once,  there  is  strong  hope 
that  the  child  will  grow  up  well  and  healthy, 
if  reared  under  good  hygienic  conditions,  in 
pure  air;  for  we  may  repeat  again  that  tuber- 
culosis is  not  inherited,  and  whatever  tendency 
may  be  inherited  can  be,  to  a  great  extent  if 
not  entirely,  overcome  by  a  proper  environ- 
ment. 

Feeding  School  Children 

Another  means  of  prophylaxis  is  the  pro- 
vision for  poor  underfed  school  children  of 
nutritious  food  by  the  school  or  public  au- 
thorities. This  is  done  in  many  countries,  but 
especially  in  Germany  and  France.  In  many 
of  the  German  cities  soup  seems  to  be  the 
usual  food  furnished.  Thus,  for  example,  in 
Strassburg,  2,800  pint  bowls  of  soup  are  daily 

238 


TUBERCULOSIS   AND   THE   CHILD 

distributed  to  the  local  schools.  In  other 
places  milk  is  furnished.  In  Dresden,  since 
1896,  there  has  existed  a  special  association 
for  feeding  poor  school  children  with  sub- 
stantial food.  Supplying  free  meals  to  chil- 
dren is  not  regarded  in  Germany  as  coming 
under  the  head  of  public  charity.  This  is  now 
done  in  many  schools  in  this  country. 

How  to  Treat  Children  with  Tuberculosis 

If  a  child  is  discovered  to  have  tuberculosis, 
its  disposition  will  depend  upon  the  state  of 
the  disease,  whether  it  is  "  closed  "  or  "  open.'* 
If  the  latter,  sanatorium  treatment  should  be 
provided,  and  this  is  done  in  many  countries, 
notably  in  France  and  Germany.  In  the 
former  country  there  are  about  4,000  beds 
available  in  the  country  or  sea-side.  In  the 
sea-side  sanatoria,  children  suffering  from 
bone,  joint  and  gland  disease  are  treated.  In 
Germany  there  are  eighteen  sanatoria  with 
900  beds  for  tuberculous  children,  and 
seventy-three  institutions  for  suspicious  cases 
and  those  suffering  from  scrofula.  In 
the  United  States,  sanatoria  for  tuberculous 
children  with  "  open  "  tuberculosis  are,  as  yet, 
but  few  and  many  more  are  needed.     Mention 

239 


TUBERCULOSIS 

has  already  been  made  of  the  Sea  Breeze 
Hospital  at  Coney  Island  for  children  with 
bone,  joint  and  gland  tuberculosis. 

If  the  child  has  "  closed "  tuberculosis,  or 
is  predisposed,  as  we  say,  to  tuberculosis,  it 
can  under  certain  conditions  attend  school, 
and  thus  at  the  same  time  continue  its  educa- 
tion and  take  the  treatment.  These  conditions 
are  fulfilled  by  the  open-air  school,  which  is 
what  its  name  indicates.  If  the  child  under- 
takes the  ordinary  school  routine,  it  is  likely 
sooner  or  later  to  break  down  under  it,  and 
thus,  from  an  economic  standpoint,  the 
money  expended  by  the  public  for  its  educa- 
tion is  lost.  In  Illinois  it  has  been  shown  that 
the  state  expends  annually  $1,187,000.00  in 
the  education  of  the  children  who  die  of 
tuberculosis  before  their  twentieth  year.  The 
open-air  school  is  established  in  some  open-air 
space,  or  park,  near  the  city,  and  the  children 
are  either  directly  out-of-doors,  or  in  the 
colder  months  of  the  year  and  in  stormy 
weather  have  some  shelter.  They  are  warmly 
clad  with  thick  clothing  appropriate  for  out- 
door life,  are  well  fed  and  have  periods  of 
rest  during  the  day. 


240 


TUBERCULOSIS    AND    THE    CHILD 

A  Typical  Out-Door  School 

For  the  out-door  school  in  Boston,  the  un- 
used portion  of  a  large  building  in  Franklin 
Park  was  utilized.  A  sunny  room  for  the 
kitchen  and  dining-room,  a  rest-room,  lava- 
tories, and  a  school-room  for  stormy  weather 
were  provided.  Upon  the  spacious  roof  with 
its  pergola,  a  tent  was  placed  for  the  chil- 
dren's desks,  which  was  the  school-room  in 
ordinary  weather,  canvas  curtains  being  pro- 
vided for  high  winds.  The  stormy  weather 
room  was  rarely,  if  ever,  used.  Each  child 
had  a  bag  of  waterproof  canvas  lined  with 
blanketing,  fitted  about  the  legs  and  up  over 
the  back.  In  addition,  everyone  had  a  thick 
ulster  overcoat,  warm  cap  and  mittens,  woolen 
stockings  and  arctic  overshoes.  The  home 
conditions  were  carefully  supervised  by  a 
nurse,  who  also  took  the  children,  to  dental,  eye, 
ear,  nose  or  throat  clinics  for  examination  or 
treatment.  A  director  and  cook  trained  the 
children  in  home  hygiene  and  economics,  and 
the  director  had  general  oversight  of  their  wel- 
fare. The  children  were  given  three  meals 
each  day  of  nutritious  food.  The  school  board 
provided  the  teachers  and  car  fares.    The  daily 

241 


TUBERCULOSIS 

routine  was  as  fellows:  On  arriving  at  the 
school  in  the  morning,  the  children  had  break- 
fast and  then  some  attended  to  their  exer- 
cises in  the  class-room,  while  others,  for  a 
short  time,  worked  in  the  kitchen  and  dining- 
room.  During  the  forenoon,  there  were 
school  exercises  with  a  recess,  breathing  exer- 
cises, play  and  preparation  for  dinner.  For 
an  hour  after  dinner,  all  the  children  rested  in 
their  sleeping  chairs.  The  afternoon  was 
passed  as  in  the  forenoon,  and  after  supper 
they  returned  to  their  homes.  One  of  the 
scholars,  when  asked  to  give  the  reason  why 
he  liked  the  open-air  school,  wrote :  "  I  like 
the  open-air  school  because  I  have  grown 
stronger  and  healthier,  also  because  I  have 
gained  six  pounds." 

The  number  of  children  in  this  school  was 
twenty-one,  from  eighteen  families,  whose 
average  number  of  inmates  was  six,  living  in 
apartments  averaging  four  rooms.  There 
were  thirty-seven  tuberculous  persons  in  these 
families,  an  average  of  two  to  each  family. 
Thirty-one  children  had  been  at  the  school  a 
month  or  more,  and  sixteen  were  returned  to 
ordinary  schools  as  arrested  cases. 

Experience  has  demonstrated,  as  the  results 
242 


TUBERCULOSIS    AND    THE    CHILD 

in  the  Boston  school  show,  that  many  of  these 
children  fully  regain  their  health,  and  are  en- 
abled to  return  to  the  ordinary  schools.  There 
are  now  in  this  country  nearly  200  open-air 
schools. 

Of  course  this  open-air  school  for  many 
children  only  partially  solves  the  problem,  for 
they  have  to  spend  the  night  at  home,  often 
under  very  unhygienic  conditions.  For  chil- 
dren thus  situated,  the  only  solution  is  resi- 
dential open-air  school  colonies. 

Another  important  preventive  measure  with 
children  is  the  care  and  protection  of  their 
teeth,  which  has  before  been  referred  to. 
When  it  is  remembered  that  a  large  portion 
of  school  children  have  decayed  teeth  so  that 
they  cannot  properly  chew  their  food,  the  im- 
portance of  this  prophylactic  measure  is  evi- 
dent. Again,  in  this  connection,  it  is  well  to 
refer  to  enlarged  tonsils  and  adenoids,  so  com- 
mon in  children,  and  which  interfere  with  full, 
free  respiration.  Children  found  to  be  habit- 
ually breathing  through  the  mouth  should  be 
examined  for  these  conditions,  and  if  they  are 
found  to  exist,  proper  measures  should  be 
taken  to  remedy  them. 


243 


TUBERCULOSIS 

Hygienic  School  Buildings 

In  the  ordinary  school  buildings  there  is 
often  much  to  be  desired  in  the  provision  of 
sufficient  space,  proper  ventilation,  light  and 
cleanliness,  and  sanitary  arrangements.  Every 
school  building  should  be  supplied  with  the 
bubbling  drinking  fountains,  now  generally 
used,  in  place  of  the  dirty  common  drinking 
cup,  and  every  schoolhouse  should  have  an 
open-air  room  where  weak  and  ansemic  chil- 
dren could  receive  the  benefits  of  the  open- 
air  system.  Children  should  be  taught  to  keep 
clean,  and  avoid  putting  dirty  things  in  their 
mouths.  Above  all,  the  school-room  should  be 
frequently  and  thoroughly  cleaned,  and  kept 
clean  and  free  from  dust,  and  an  occasional 
regular  disinfection  would  destroy  many  a 
lurking  germ.  The  provision  of  play-grounds 
for  children  now  being  so  actively  promoted 
in  the  United  States,  both  by  legislation,  as  in 
Massachusetts,  and  by  voluntary  associations, 
is  another  evident  means  of  improving  the 
health  of  the  child,  and  hence  a  valuable  pre- 
ventive measure  against  tuberculosis.  Other 
preventive  means  are  children's  gardens, 
school  farm  leagues,  the  provision  of  swim- 
ming schools,  or  tanks  for  school  children,  as 
in  Brookline,  Mass.,  gymnastics,  breathing  ex- 

244 


TUBERCULOSIS    AND    THE    CHILD 

crcises,  frtquent  excursions  into  the  country; 
and  all  the  various  instrumentalities  for  im- 
proving the  child's  health  and  giving  him 
fresh  air.  The  elements  of  hygiene  are  now 
almost  universally  taught  in  the  schools,  and, 
in  addition,  simple  facts  regarding  tubercu- 
losis. In  a  little  pamphlet  arranged  for  school 
children,  called  "  The  True  Story  6i  Tubercu- 
losis," the  following  useful  rules  are  given : 

Rules  for  Children 

1.  Do  not  spit. 

2.  Do  not  let  others  spit. 

3.  If  you  have  a  cough,  and  must  spit,  use 
a  paper  napkin  or  a  piece  of  newspaper,  and 
put  it  in  the  stove. 

4.  Get  plenty  of  fresh  air;  keep  your  win- 
dows open  at  night,  no  matter  what  the 
weather  may  be. 

5.  Do  not  allow  anyone  to  kiss  you  on  the 
lips. 

6.  Do  not  stay  near  anyone  who  has  a 
cough. 

7.  Take  a  warm  bath  once  or  twice  a  week, 
and  bathe  your  face,  neck,  chest  and  arms 
with  cold  water  every  morning. 

245 


TUBERCULOSIS 

8.  Always  hold  a  handkerchief  over  your 
mouth  and  nose,  when  you  cough  or  sneeze. 

9.  Always  breathe  through  your  nose.  If 
it  is  stopped  up,  and  you  have  to  open  your 
mouth  to  breathe,  go  to  a  doctor  or  dispen- 
sary. You  cannot  be  well  unless  you  breathe 
through  your  nose. 

10.  Do  not  wrap  heavy  mufflers  or  furs 
around  your  neck. 

11.  Use  your  toothbrush  after  each  meal. 

12.  Wash  your  hands  with  soap  and  water 
before  each  meal. 

13.  Never  eat  too  much. 

14.  Drink  all  the  milk  you  can  get,  and 
very  little  tea  or  coffee. 

15.  Do  not  lie  on  the  bed  with  a  sick  per- 
son. 

16.  Avoid  children  who  have  any  contagious 
disease. 

17.  Do  not  spit  on  your  slate,  or  put  your 
fingers  in  your  mouth,  before  you  turn  the 
pages  of  a  book. 

18.  Do  not  put  things  in  your  mouth  that 
other  children  have  had  in  theirs,  such  as 
whistles,  spit  blowers,  chewing  gum  and  pen- 
cils. Do  not  bite  from  the  same  apple  that 
some  one  else  has  been  eating. 

246 


TUBERCULOSIS    AND    THE    CHILD 

19.  And   last  as  well   as  first,  DO   NOT 
SPIT. 


Teachers  and  Tuberculosis 

Teachers  are  said  to  suffer  heavily  from 
tuberculosis,  and  Prof.  Brouardel  states  that 
one-fifth  of  the  teachers  of  Paris  are  tubercu- 
lous. Although  teachers  in  other  countries 
probably  do  not  suffer  from  tuberculosis  to 
this  extent,  still  there  is  sufficient  reason  to 
require  the  periodic  examination  of  all  pub- 
lic school  teachers,  and  particularly  on  enter- 
ing* upon  their  work,  as  is  done  in  Denmark, 
where  every  teacher,  on  appointment  to  a 
public  school,  is  obliged  to  present  a  medical 
certificate,  not  more  than  three  months  old, 
stating  that  he  (or  she)  is  not  affected  by  any 
contagious  form  of  tuberculosis  of  the  lungs 
or  throat. 

The  medical  inspection  of  schools  is  now 
general,  but  this  does  not  always  include  the 
examination  of  the  children  as  regards  tuber- 
culosis. From  what  we  have  learned  of  the 
prevalence  of  tuberculosis  among  children,  it 
would  seem  that  such  an  examination,  as  se- 
rious an  undertaking  as  it  would  be,  should, 
at  least  once  a  year,  be  done. 

247 


TUBERCULOSIS 

The  Home  and  Tuberculosis 

After  all,  it  is  in  the  home  where  there  is 
a  case  of  tuberculosis  that  the  greatest  dan- 
ger to  the  child  exists,  and  it  is  where  our 
strenuous  efforts  must  be  made.  Dr.  Low- 
man  of  Cleveland  states  the  fact  that  of  504 
children  examined  by  him,  who  were  from 
homes  where  there  was  a  case  of  tuberculosis, 
xhirty-eight  had  positive  tuberculosis  and  six- 
ty-four could  easily  become  so  infected  under 
unfavorable  conditions.  From  the  standpoint 
of  the  child,  the  value  of  the  visiting  nurse 
in  connection  with  the  dispensary,  of  which 
we  have  before  spoken,  becomes  more  ap- 
parent, for  whenever  a  case  of  tuberculosis 
is  discovered,  the  nurse  visits  the  home  and 
urges  all  the  children  to  be  examined.  And, 
again,  the  measures  taken  by  the  Information 
Bureaus  in  Germany,  which  have  been  de- 
scribed, in  the  protection  of  other  members  of 
the  family  in  a  tuberculous  household,  are 
shown  in  this  connection  to  be  of  the  highest 
importance  in  safeguarding  the  child. 

A  Complete  Programme 

Finally,  in  order  to  prevent  and  control  tu- 
248 


TUBERCULOSIS    AND    THE    CHILD 

berculosis  in  children  and  during  school  age, 
we  must  first:  Know  what  children  are  in- 
fected and  those  who  live  in  families  where 
there  is  a  case  of  tuberculosis.  This  can  be 
done,  in  part,  through  the  visiting  nurse  of 
the  dispensary  or  through  whatever  agency  is 
employed  to  investigate  the  home  of  the  con- 
sumptive, and  in  a  more  complete,  and  the  only 
satisfactory  way,  by  a  periodic  examination  of 
the  lungs  of  all  school  children.  Second :  All 
children  who  are  found  to  have  "  open,"  con- 
tagious, tuberculosis  must  be  placed  in  sana- 
toria or  hospitals,  or  receive  treatment  and 
care  in  the  country  similar  to  sanatorium 
treatment.  Third :  "  Closed,"  non-contagious 
cases  should  be  placed  in  open-air  schools, 
and,  during  the  summer,  in  vacation  colonies 
or  children's  camps;  or,  where  the  home  con- 
ditions are  bad,  in  residential  open-air  schools 
or  colonies.  Fourth :  Healthy  children  in 
families  where  there  is  a  case  of  tuberculosis 
should  either  be  removed  from  the  family  or 
kept  under  careful  observation,  or  the  con- 
sumptive member  of  the  family  should  be  re- 
moved. Fifth:  All  weak,  sickly  school  chil- 
dren who  could  easily  become  tuberculous 
under  unfavorable  conditions  should  be  placed 

249 


TUBERCULOSIS 

in  separate  rooms  or  schools  where  they  can 
receive  special  hygienic  attention,  such  as 
frequent  intermissions  for  rest,  shorter  hours, 
food,  and  an  abundance  of  fresh  air.  Sixth: 
The  children  of  consumptive  mothers  should 
not  be  nursed  by  them,  and  should  not  re- 
main with  them.  Seventh:  All  school  teach- 
ers should  have  their  lungs  periodically  ex- 
amined. Eighth:  School  buildings  should 
be  so  constructed  as  to  be  thoroughly  venti- 
lated and  at  all  times  have  pure,  fresh  air 
and  be  kept  absolutely  clean.  In  every  school 
building  there  should  be  one  so-called  open-air 
room.  Ninth :  School  children  should  be  in- 
structed in  the  elements  of  hygiene  and  clean- 
liness, and  the  simple  facts  of  tuberculosis  and 
its  prevention.  Tenth:  Children  suffering 
from  bone,  joint  or  gland  tuberculosis  should 
be  sent  to  sea-side  sanatoria. 

The  above  may  appear  to  be  a  programme 
of  perfection  and  too  extensive  for  any  com- 
munity to  undertake,  but  no  labor  or  expense 
is  too  great  in  the  protection  of  the  child 
from  tuberculosis,  from  which,  as  we  have 
seen,  it  suffers  so  severely.  What  can  appeal 
more  strongly  to  the  sympathy  and  interest 
of  any  anyone  than  the  protection  of  the  in- 

250 


TUBERCULOSIS    AND    THE    CHILD 

nocent,  helpless  child?  Moreover,  it  is  an 
economic  gain  to  the  community  to  save  the 
child  for  future  usefulness  and  contributions 
to  the  community,  rather  than  to  expend  large 
sums  upon  its  care  when,  later,  active  tuber- 
culosis has  developed. 

"  The  field  in  which  the  decisive  battle  of 
our  future  campaign  against  tuberculosis  must 
be  fought,  is  the  home,"  says  Dr.  Woods 
Hutchinson.  "  Our  chief  enemy,  infection  in 
early  childhood."  Both  from  an  economic,  a 
selfish,  and  a  sentimental  point  of  view,  the 
most  strenuous  efforts  should  be  devoted  to 
the  prevention  and  arrest  of  tuberculosis  in 
children,  for  the  child  of  to-day  is  the  man  of 
to-morrow,  and  has  infinite  and  untold  pos- 
sibilities. 


251 


XIII.    THE   GOVERNMENT   AND   TU- 
BERCULOSIS 

XN  the  evolution  of  popular  govern- 
ment, the  first  step  is  to  render 
life  safe  and  afford  protection  to 
property — to  maintain  law  and 
order — for  no  progress  and  ad- 
vancement in  civilization  can  ensue  unless  a 
man  is  made  to  feel  that  he  can  pursue  his 
avocation  unmolested  and  remain  secure  in 
the  possession  of  that  which  he  has  gained  by 
his  labor.  As  governments  have  developed, 
however,  they  have  assumed  many  other  func- 
tions with  the  object  of  increasing  the  wel- 
fare and  happiness  of  the  people,  which  a 
general  government,  with  all  its  power  and 
resources,  can  best  or  only  accomplish.  Thus, 
for  example,  the  general  government  has  pro- 
vided or  aided  in  intercommunication  between 
the  states  and  foreign  countries  by  means  of 
the  post  office  and  appropriations  for  the 
building  of   pathways   of   communication   in 

252 


GOVERNMENT  AND  TUBERCULOSIS 

one  way  or  another.  Again,  the  general  gov- 
ernment has  aided  the  people  in  the  cultiva- 
tion of  the  soil  by  agricultural  laboratories, 
experimental  stations,  and  the  free  distribu- 
tion of  seeds.  The  government  is  now  re- 
claiming the  desert  wastes  of  the  West  on  a 
vast  scale  by  means  of  irrigation,  and  then 
returning  the  watered  and  fertile  fields  to  the 
people  for  their  cultivation.  It  is  protecting 
the  forests  and  coal  fields,  investigating  cat- 
tle diseases,  and  in  very  many  other  ways 
doing  for  the  people  those  things  which  they 
could  not  do,  or  only  with  great  difficulty  and 
slowly  do  for  themselves,  and  which  promote 
the  progress  and  well-being  of  the  whole 
country.  Likewise  states  follow  in  the  foot- 
steps of  the  general  government  and  perform 
similar  offices  for  their  people.  Cities,  again, 
provide  public  libraries,  parks,  baths  and  play- 
grounds for  their  constituencies. 

Thus,  it  is  recognized  by  modern  govern- 
ments that  whatever  adds  to  the  efficiency, 
welfare  and  happiness  of  the  people,  and  which 
they  individually  cannot  do  for  themselves, 
may  be  properly  assumed  by  the  people  col- 
lectively, that  is,  by  the  government,  national, 
state  or  city. 

253 


TUBERCULOSIS 

The  Government  Should  Protect  the  Health  of 
the  People 

The  realization  that  the  government  could 
promote  the  welfare  of  the  people  by  provi- 
sions for  the  protection  of  their  health  seems 
to  have  come  more  slowly,  and  most  of  the 
steps  which  have  been  taken  for  this  purpose 
by  the  general  government  have  been  of  com- 
paratively recent  date,  as,  for  example,  the 
pure  food  law  so  recently  enacted,  and  laws 
prohibiting  or  restricting  child  labor.  It  is 
obvious  that  if  we  would  efficiently  protect 
life  and  property,  to  say  nothing  of  adding 
to  the  welfare  and  happiness  of  the  people, 
the  government  must  aid  in  protecting  them 
from  preventable  diseases  which  unnecessar- 
ily destroy  life  and  entail,  through  sickness 
and  untimely  death,  great  financial  loss.  This 
is  especially  true  of  such  a  prevalent  and  wide- 
spread disease  as  tuberculosis.  The  people 
cannot  individually  and  unaided  successfully 
contend  with  such  a  gigantic  task  as  eradicat- 
ing this  Great  White  Plague.  Private  and 
voluntary  effort  must  be  supplemented  by 
governmental  aid,  either  from  the  general 
government  or  state  intervention.  The  lat- 
ter— the  state — as  we  have  seen,  is  realizing 

254 


GOVERNMENT    AND   TUBERCULOSIS 

its  duty  in  this  respect  far  better  than  the 
general  government. 

In  most  of  the  European  governments,  as 
has  been  already  shown,  the  tuberculosis  Cru- 
sade is  aided  both  by  official  sanction  and 
public  appropriations  for  sanatoria,  hospitals, 
and  the  educational  propaganda.  In  the 
United  States  v^e  have  the  great  army  and 
navy  departments  with  huge  annual  appro- 
priations of  millions  of  dollars  for  the  pro- 
tection of  the  life  and  property  of  the  people 
at  home  and  abroad.  We  have  the  Depart- 
ment of  Commerce  and  Labor  to  promote  their 
commercial  and  industrial  welfare;  the  De- 
partment of  Agriculture  to  aid  and  show  the 
farmer  how  he  can,  to  the  greatest  advant- 
age, till  his  soil  and  produce  the  crops  best 
adapted  to  his  land. 

But,  unfortunately,  we  have  no  specific 
Bureau  of  Public  Health  to  investigate  mat- 
ters connected  with  the  health  of  the  people, 
to  advocate  and  carry  out  measures  calculated 
to  protect  the  people's  health,  or  to  control 
prevalent  diseases. 

What  Former  President  Roosevelt  Says 

In  his  last  message  to  Congress,  President 
255 


TUBERCULOSIS 

Roosevelt  said :  "  The  recent  International 
Congress  on  Tuberculosis  has  made  us  pain- 
fully aware  of  the  inadequacy  of  American 
public  health  legislation.  This  nation  can- 
not afford  to  lag  behind  in  this  world-wide 
battle  now  being  waged  by  all  civilized  peo- 
ple with  the  microscopic  foes  of  mankind,  nor 
ought  we  longer  to  ignore  the  reproach  that 
this  government  takes  more  pains  to  protect 
the  lives  of  hogs  and  cattle  than  of  human 
beings."  Under  a  National  Bureau  of  Health, 
very  many  of  the  yet  unsettled  questions  re- 
garding tuberculosis  could  properly  be  investi- 
gated in  government  laboratories  and  the  re- 
sults practically  applied  for  the  benefit  of  all 
people.  The  work  such  a  National  Bureau  of 
Health  could  do  in  stamping  out  tuberculosis 
is  almost  incalculable,  and  if  but  a  small 
fraction  of  the  money  new  appropriated  for 
the  army  and  navy  should  be  devoted  to  this 
purpose,  we  should  see  the  disease  diminish 
with  ever-increasing   rapidity. 

State  Governments  and  Tuberculosis 

With  but  few,  if  any,  exceptions,  the  vari- 
ous states,  as  we  have  seen,  have  actively  en- 
tered into  the  tuberculosis  campaign,  both  by 

256 


GOVERNMENT   AND   TUBERCULOSIS 

the  enactments  of  anti-tuberculosis  laws  and 
the  appropriation  of  money  for  sanatoria  and 
other  purposes.  Nevada,  Utah,  Wyoming 
and  Mississippi  are  the  only  states  which  have 
made  no  sanatorium  or  hospital  provision  for 
consumptives.  Only  a  few  years  ago,  Penn- 
sylvania appropriated  one  million  dollars 
for  dispensaries,  sanatoria  and  the  study 
of  tuberculosis.  The  act  of  the  legislature 
making  this  provision  shows  such  a  broad 
and  comprehensive  grasp  of  the  subject  that 
it  is  well  worth  while  quoting  as  a  model  for 
other  state  governments.  The  amount  ap- 
propriated was  divided  into  two  sums:  One 
of  $600,000,  "  to  provide  for  the  establish- 
ment and  maintenance  of  one  or  more  sep- 
arate sanatoria  or  colonies  in  Pennsylvania 
for  the  free  care  and  treatment  of  indigent 
persons  suffering  from  tuberculosis  and  mak- 
ing an  appropriation  therefor,"  and  the  other 
part  of  $400,000,  "to  enable  the  department 
of  health  to  establish  and  maintain,  at  such 
places  in  the  state  as  may  be  deemed  neces- 
sary, dispensaries  for  the  free  treatment  of 
indigent  persons  affected  with  tuberculosis, 
for  the  dissemination  of  knowledge  relating 
to  the  prevention  and  cure  of  tuberculosis, 
for  the  study  of  social  and  occupational  con- 

257 


TUBERCULOSIS 

ditions  that  predispose  to  its  development, 
and  for  continuing  research  experiments  for 
the  establishment  of  possible  immunity  and 
cure  of  said  disease." 

Probably,  as  Dr.  Farrand  thinks,  the  most 
efficient  work  of  the  states  can  be  done  through 
their  boards  of  health,  which,  for  the  state, 
correspond  to  a  National  Bureau  of  Health. 
State  boards  of  health  have  laboratories  for 
the  free  examination  of  sputum;  they  dis- 
seminate tuberculosis  literature;  they  investi- 
gate the  tuberculosis  conditions  in  their  states, 
and,  through  them,  laws  passed  by  the  legis- 
lature are  put  into  execution.  It  is  an  en- 
couraging sign  to  know  that  the  expenditures 
of  many  state  boards  of  health  for  health 
purposes  have  rapidly  increased  within  the 
last  ten  to  fifteen  years,  whereas,  a  hundred 
years  ago,  neither  nation  nor  state  spent  one 
cent  for  the  protection  of  health.  Thus,  in 
Pennsylvania,  for  example,  up  to  1904,  the 
annual  appropriation  was  only  $6,500,  while 
for  the  two  years  of  1906  and  1907  it  was 
$2,100,600,  and  in  1913,  it  was  $1,629,195  for 
tuberculosis  alone.  In  Massachusetts,  in  1895, 
the  State  Board  of  Health  expended  $56,876, 
and  in  1913,  $1,138,521  for  tuberculosis  besides 
the  expenditure  for  other  preventable  diseases. 

258 


GOVERNMENT   AND    TUBERCULOSIS 

Fighting  one  preventable  disease  stimulates 
the  health  boards  and  the  people  to  fight  other 
preventable  diseases,  and  to  generally  raise 
the  standard  of  health  requirements.  The  tu- 
berculosis warfare  has  given  an  immense  im- 
petus towards  the  improvement  of  health  con- 
ditions in  general. 

A  Comprehensive  Scheme  for  the  State 

Some  states  have  especial  tuberculosis  com- 
missions for  the  purpose  of  studying  the  prev- 
alence and  conditions  of  the  disease  within 
their  own  borders,  instructing  the  people  with 
regard  to  the  same,  suggesting  the  best  means 
of  combating  it,  and  constructing  sanatoria. 

Whether  it  is  done  by  such  a  commission, 
or  by  the  State  Board  of  Health,  a  compre- 
hensive scheme  adapted  to  the  needs  of  the 
state  should  be  arranged,  with  a  fixed  yearly 
appropriation,  so  that  a  systematic  and  con- 
tinued warfare  can  be  vigorously  pushed. 
Such  larger  undertakings  as  the  erection  of 
sanatoria  for  early  cases  and  consumptive  hos- 
pitals for  advanced  cases,  which  are  beyond 
the  means  of  voluntary  and  individual  effort, 
would  naturally  fall  within  the  field  of  public 
provision. 

What  is  most  urgently  needed  at  the  pres- 

259 


TUBERCULOSIS 

ent  time  is  greater  and  more  adequate  pro- 
vision by  the  state  for  the  isolation  of  ad- 
vanced cases.  Nothing  will  so  surely  and 
steadily  reduce  this  prevalence  of  tuberculo- 
sis, as  we  have  seen,  as  such  provision  for 
hopeless  cases,  and  many  states  and  localities 
are  now  doing  this. 

City  Governments 

The  cities  in  their  official  capacity  have, 
and  are,  doing  more  or  less  in  the  tuberculosis 
warfare.  New  York  City  is,  perhaps,  the 
most  conspicuous  example  of  a  city  possess- 
ing a  complete  programme  for  fighting  the 
disease,  and  its  efforts  have  been  made 
through  the  initiative  and  continued  aggres- 
siveness of  its  very  competent  Health  Depart- 
ment. It  was  the  first  city  in  the  country  to 
pass  a  notification  law.  It  has  established  its 
own  sanatorium,  and  provides  extensive  ac- 
commodations for  advanced  cases.  It  main- 
tains 15  tuberculosis  dispensaries,  requires 
adequate  disinfection  of  premises  which  have 
been  occupied  by  a  consumptive,  and  carries 
on  very  many  other  administrative  schemes 
for  the  prevention  and  care  of  tuberculosis. 
"  At  the  present  time,"  says  Dr.  Biggs,  the 
medical  officer  of  the  Department  of  Health, 

260 


GOVERNMENT   AND    TUBERCULOSIS 

"  there  is  no  other  city  in  the  world  in  which 
the  health  authorities  have  so  thoroughly  or- 
ganized the  tuberculosis  campaign  as  in  the 
city  of  New  York."  That  this  campaign  has 
been  effective  is  shown  by  the  fact  that  the 
mortality  from  tuberculosis  has  been  reduced 
more  than  53  per  cent,  since  the  Depart- 
ment of  Health  undertook  fighting  tuberculo- 
sis twenty-five  years  ago.  Other  cities  have 
followed  the  admirable  example  of  New 
York  to  a  greater  or  less  extent,  in  the  es- 
tablishment of  day  camps,  dispensaries,  mu- 
nicipal sanatoria,  and  hospitals  for  advanced 
cases.  Boston  has  all  of  these,  with  the  ex- 
ception of  a  sanatorium,  which  is  provided 
by  the  state. 

Large  Appropriations  Necessary 

We  now  possess  ample  knowledge  intelli- 
gently to  control  and  prevent  tuberculosis,  al- 
though, as  has  been  said,  there  are  unsolved 
problems  regarding  the  disease  which  are 
still  to  be  worked  out  in  the  laboratories  and 
clinics.  The  task  of  control,  however,  is 
one  of  such  gigantic  magnitude  that  it  re- 
quires large  sums  of  money  to  accomplish 
it,  and  this  must  be  furnished  through  public 
appropriations.     "  Public  Health  is  Purchase- 

261 


TUBERCULOSIS 

able,"  as  the  motto  of  the  Department  of 
Health  of  New  York  City  says.  As  tuber- 
culosis is  a  people's  disease,  a  "  disease  of 
the  masses,"  the  people  must  collectively, 
through  their  government,  furnish  the  means 
to  rid  themselves  of  it.  To  do  this  will  be  a 
remunerative  investment,  and  the  return  will 
be  in  the  preservation  of  so  many  lives  capable 
of  adding  greatly  to  the  wealth  of  the  com- 
munity. It  is  like  borrowing  money  for  any 
great  public  improvement,  which  will  pay  for 
itself  by  the  added  value  it  brings  to  the  com- 
munity. All  the  many  existing  laws  and  pro- 
visions made  by  the  states  and  cities  for  the 
protection  and  improvement  of  the  health  of 
the  people,  such  as  factory  inspection  laws, 
those  regarding  tenement-house  construction 
and  inspection,  the  limiting  of  the  hours  of 
labor,  and  many  others,  are  obviously  indirect 
means  for  the  prevention  of  tuberculosis  by 
increasing  the  resisting  power  of  the  individ- 
ual. 

What  Foreign  Nations  are  Doing 

In  Germany,  there  is  a  National  Bureau 
of  Health  presided  over  by  a  cabinet  officer, 
which  has  exhaustively  investigated  the  tu- 
berculosis problem  in  all  its  aspects,  and,  as 

262 


GOVERNMENT   AND    TUBERCULOSIS 

a  result  of  this  study,  national  laws  have 
been  enacted,  such  as  the  prohibition  of  in- 
discriminate expectoration,  compulsory  noti- 
fication, disinfection,  and  others ;  while  public 
appropriations  have  been  made  for  the  scien- 
tific study  of  tuberculosis,  the  erection  of  san- 
atoria, etc.  The  Compulsory  Workingmen's 
Insurance  Societies,  already  described,  were 
established  by  imperial  decree,  in  1881.  In 
the  German  army,  careful  attention  is  given 
to  the  restriction  of  tuberculosis,  and  when  a 
case  is  discovered,  the  soldier  is  removed  to 
one  of  the  government  sanatoria,  or  other- 
wise isolated,  and  treated.  Thus  Germany 
shows  its  wisdom  in  recognizing  the  equal 
duty  and  necessity  of  protecting  the  health 
of  the  workingman,  who  furnishes  the  rev- 
enue, as  well  as  that  of  the  soldier,  who  fur- 
nishes the  protection  to  life  and  property.  The 
German  cities  have  also  been  active  in  their 
official  capacity  in  the  tuberculosis  campaign. 
Some  have  erected  municipal  sanatoria,  as  Ber- 
lin, Strassburg,  etc.  In  others,  polyclinics,  or 
dispensaries,  are  maintained. 

In  France  a  permanent  commission  has  been 
appointed  by  the  Minister  of  the  Interior  to 
study  the  causes  of  tuberculosis  and  present 
plans  for  its  prevention.     In  1902  the  Minister 

263 


TUBERCULOSIS 

of  Public  Instruction  caused  to  be  distributed 
in  all  the  schools,  colleges,  and  boarding- 
schools,  a  circular  with  instructions  concern- 
ing the  prevention  of  tuberculosis.  The  gov- 
ernment requires  all  the  post  offices  to  be 
inspected  to  see  that  proper  measures  of  hy- 
giene are  adopted  for  the  protection  of  the 
staff  and  the  public.  The  city  of  Paris 
founded  and  maintains  on  the  seacoast  a 
large  hospital  of  750  beds  for  tuberculous 
children.  Official  aid  by  the  government  and 
cities  is  given  in  the  establishment  of  san- 
atoria and  dispensaries  and  in  other  anti- 
tuberculosis work. 

In  England  there  is  a  British  Royal  Com- 
mission for  Tuberculosis,  which  was  appointed 
in  1901,  with  the  especial  purpose  of  investi- 
gating the  difference  between  the  tuberculosis 
of  cattle  and  that  of  human  beings,  and  it 
has  already  published  several  volumes  as  the 
result  of  its  experiments  and  investigations. 
Many  English  cities,  by  public  appropriations, 
provide  beds  for  their  consumptives,  either 
in  already  existing  sanatoria,  or,  as  in  the 
case  of  tlie  city  of  Birmingham,  already  men- 
tioned, establish  their  own  separate  insti- 
tutions. The  National  Insurance  Act  now 
provides  a  comprehensive  plan  with  a  liberal 

264 


GOVERNMENT   AND    TUBERCULOSIS 

appropriation  for  the  establishment  of  sana- 
toria and  other  provisions  for  fighting  tuber- 
culosis. 

Mention  has  already  been  .made  of  govern- 
mental activity  in  the  prevention  of  tuberculo- 
sis in  other  European  countries.  We  have 
seen  what  the  governments  of  Sweden,  Den- 
mark, Norway  and  others  have  done.  In 
Japan,  the  imperial  government  has  created 
a  large  hospital  for  the  study  and  treatment 
of  tuberculosis.  In  the  United  States,  we 
have  also  seen  what  many  states  and  cities  are 
doing  in  their  official  capacity  to  stamp  out 
tuberculosis,  and  the  growing  recognition 
throughout  the  country  of  the  duty  of  the 
several  states  in  this  respect.  Over  and  above 
all  this,  however,  there  is  needed,  as  Presi- 
dent Roosevelt  so  emphatically  pointed  out, 
"  public  health  legislation," — a  bureau  of  pub- 
lic health, — which  will  actively  engage  in  the 
battle  against  tuberculosis.  ''  Science  has 
shown,"  says  Dr.  Vaughn,  "  that  disease  is 
one  of  the  most  destructive  agents  to  both 
property  and  life,  and  that  many  diseases  are 
preventable.  Consequently,  the  government 
that  does  not  put  forth  every  possible  effort 
to  protect  the  property  and  lives  of  its  citi- 
zens against  disease  is  not  doing  its  duty." 

265 


XIV.  THE  FACTORY  AND  THE  WORK- 
SHOP IN  THEIR  RELATION  TO  TU- 
BERCULOSIS 

QEXT  to  unsanitary  dwellings  in 
crowded  quarters  of  the  city,  the 
factory  and  workshop  are,  per- 
haps, the  most  frequent  sources  of 
tuberculous  infection,  and  from 
similar  causes.  In  the  factory  and  the  work- 
shop the  operatives  are  crowded  together,  often 
under  unsanitary  conditions,  such  as  insuffi- 
cient ventilation  and  Hght,  dust  and  dirt ;  all  of 
which  are  conducive  to  a  deterioration  of  one's 
health,  and  hence  to  the  preparation  of  a  suit- 
able soil  for  the  bacillus.  Then  frequently 
the  seed  is  at  hand  in  a  tuberculous  workman 
who  is  negligent  in  the  safe  disposal  of  his 
sputum.  Thus  the  crop  of  tuberculosis  is 
produced,  and  abundant  observation  has 
proved  the  frequency  of  its  occurrence.  In 
general,  as  we  know,  the  mortality  of  opera- 
tives in  shop,  mill  or  factory,  is  much  higher 
than  that  of  those  engaged  in  agriculture  and 

266 


FACTORY   AND   WORKSHOP 

out-door  pursuits.  Among  men  in  mechanical 
and  manufacturing  industries,  the  consump- 
tion death  rate  is  18.8  per  cent,  of  the  mortal- 
ity from  all  causes,  whereas  it  is  only  9.5 
per  cent,  among  men  in  out-door  occupations. 
In  England  a  similar  difference  is  noted,  and 
such  is  undoubtedly  the  case  in  industrial  in- 
door occupations  in  other  countries. 

Importance  of  Protecting  the  Health  of  Wage- 
Earners 

This  high  mortality  from  tuberculosis 
among  workers  in  mills  and  factories  is  a 
product  or  penalty  of  the  present-day  civili- 
zation, hence  it  is  a  duty  of  civilization  to 
remedy  it,  and  it  is  of  the  utmost  importance 
that  most  careful  consideration  should  be 
given  to  this  "  occupation  disease,"  as  it  has 
been  called,  for  the  protection  of  the  lives  and 
physical  well-being  of  the  wage-earners  of 
any  country  means  the  safeguarding  of  its 
material  prosperity.  The  influence  of  the  de- 
terioration of  the  physical  condition  from 
manufacturing  industries  is  well  illustrated 
by  the  experience  of  England  in  the  Boer 
war,  v/hen  so  many  recruits  taken  from  in- 
dustrial employments  were  found  physically 

267 


TUBERCULOSIS 

unfit  for  army  service.  To  maintain  a  good 
defensive  power,  a  country  must  preserve  the 
health  and  physical  integrity  of  its  common 
people,  from  whom  the  mass  of  its  defenders 
are  drawn.  ''  There  is  no  doubt,"  says  a  re- 
cent writer  referring  to  Germany,  "  that  her 
educational  system,  military  discipline,  pater- 
nal supervision  of  the  sanitation  of  industrial 
establishments,  control  of  insurance  of  em- 
ployees, all  lead  to  the  development  of  a 
strong,  healthy  working  class,  and  when  to 
these  there  is  added  the  development  of  a  high 
moral  character,  the  result  is  a  nation  well  nigh 
impregnable  to  attack." 

Remedies  for  Evils  of  Industrial  Infection 

In  order  to  remedy  this  evil  of  "  industrial 
infection,"  as  it  is  called,  we  must  work  in 
two  main  directions :  first,  protect  the  well 
employees  from  infection  through  tubercu- 
lous fellow-workmen ;  and,  second,  so  regulate 
and  guard  the  work-places — the  shops  and 
factories — that  all  those  injurious  influences 
which  produce  a  favorable  soil,  a  lowering  of 
the  resisting  power,  may  be,  so  far  as  possible, 
eliminated, — in  brief,  afford  the  workman  a 
healthy  environment  to  work  in.  With  a  large 
number  of  operatives  in  a  confined  space,  it  is 
almost  inevitable  that  some  of  them  should  be 

268 


FACTORY    AND    WORKSHOP 

tuberculosis,  though  able  to  work,  and  the 
problem  is,  how  to  discover  and  render  safe, 
or  remove  such  tuberculous  operatives.  The 
solution  is  difficult,  and  the  only  perfect  way 
would  be  to  examine  all  persons  upon  their 
entrance  into  the  factory,  or  mill,  and  periodic- 
ally thereafter.  In  a  few  instances  this  has 
been  done,  as  in  a  large  chocolate  factory  in 
Bristol,  England,  where  every  person  seeking 
employment  has  to  undergo  an  examination 
of  the  heart  and  lungs.  At  present,  however, 
a  general  application  of  this  plan  would  seem 
to  be  impracticable  unless  legal  enactment  by 
the  state  should  require  it,  and  there  is  much 
to  be  said  in  favor  of  this.  Massachusetts,  for 
example,  now  requires  that  all  factories  shall 
be  well  lighted,  well  ventilated  and  kept  clean ; 
that  cuspidors  shall  be  provided;  that  there 
shall  be  proper  sanitary  arrangements ;  that 
medical  and  surgical  appliances  shall  be  kept 
in  all  factories;  that  proper  egresses,  fire-es- 
capes, and  fire  extinguishers  shall  be  provided : 
and  inspectors  are  appointed  to  see  that  these 
things  are  done.  Why  not  extend  this  pater- 
nal care  of  its  working  people,  and  require  a 
periodic  examination  of  the  lungs  of  each 
operative,  perhaps  of  equal  or  greater  value 
with  these  other  requirements,  when  one  con- 

269 


TUBERCULOSIS 

siders  the  frequency  of  tuberculosis  among  in- 
door workers? 

What  is  Now  Being  Done 

Much,  however,  is  already  being  done  by 
considerate  employers  and  tuberculosis  asso- 
ciations for  the  detection  of  tuberculosis 
among  employees  and  provision  for  their  treat- 
ment. Placards  and  notices  are  displayed  in 
workrooms,  calling  attention  to  the  dangers 
of  indiscriminate  spitting,  and  giving  some  of 
the  facts  regarding  tuberculosis  and  its  symp- 
toms. Cuspidors  are  provided.  In  Massa- 
chusetts these  are  required  by  law.  In  the 
government  printing  office  in  Washington, 
where  4,800  persons  are  employed,  about 
1,400  cuspidors  are  provided,  which  are 
cleaned  and  sterilized  with  boiling  water  and 
steam.  In  many  large  establishments,  the  em- 
ployers offer  free  examination  of  the  lungs 
to  all  their  employees  who  think  they  may 
have  tuberculosis,  and  if  a  case  is  discovered, 
it  is  offered  an  opportunity  to  enter  a  state 
sanatorium  for  a  certain  period  at  the  expense 
of  the  employer.  Overseers  are  asked  to  seek 
out  all  who  have  a  cough,  or  show  suspicious 
symptoms  of  tuberculosis.  In  a  large  manu- 
facturing establishment  in  New  England,  the 
following  notice  was  posted  by  the  manage- 
ment: 

270 


FACTORY   AND    WORKSHOP 

"  There  is  at  present  a  strong  effort  being 
made  to  exterminate  the  disease,  consumption. 
It  is  known  to  be  very  easily  curable  if  the 
treatment  is  begun  in  the  early  stages,  and 
readily  prevented  by  proper  ways  of  living. 
The  hopeless  or  incurable  cases  are  those  that 
have  been  allowed  to  go  neglected.  In  order 
to  aid  in  this  matter  we  have  provided,  free 
of  expense  to  our  employees,  a  physician  who 
is  especially  interested  in  this  disease,  and 
who  can  advise  about  the  best  treatment;  and 
for  the  purpose  of  helping  those  who  may  be 
afflicted  and  protecting  others,  we  shall  feel 
free  to  suggest  an  examination  of  any  who 
may  possibly  have  symptoms  of  this  disease 
as  indicated  by  coughing,  loss  of  appetite  or 
weight.  If  the  lungs  are  found  to  be  healthy, 
there  is  then  no  need  to  worry;  if  on  the 
other  hand,  there  is  any  disease,  it  can  be 
treated  before  it  is  too  late." 

In  a  considerable  number  of  factories  in 
various  manufacturing  cities  in  Massachu- 
setts, the  employers  are  co-operating  with  the 
State  Inspectors  of  Health,  who  are  physi- 
cians, in  detecting  cases  of  tuberculosis  among 
their  employees,  or  employ  physicians  them- 
selves for  the  purpose,  and  when  an  early 
case  is  found,  it  is  sent  to  the  State  Sanato- 
rium at  the  expense  of  the  employer. 

271 


TUBERCULOSIS 

The  Plan  of  Mutual  Aid  in  Connecticut 

In  Connecticut  a  movement  has  been  or- 
ganized in  most  of  the  large  manufacturing 
cities,  whereby  both  the  employers  and  em- 
ployees unite  in  caring  for  tuberculous  work- 
men in  their  respective  factories.  A  certain 
sum  of  money  is  subscribed  by  the  working- 
men,  and  a  sum  equal  to  the  total  amount 
contributed  by  his  men  is  generally  contrib- 
uted by  the  employer,  which  combined  sum 
is  used  for  the  treatment  of  needy  consump- 
tive workmen  in  sanatoria.  The  various  fac- 
tories thus  contributing  form  a  sort  of  Union 
whereby  the  weaker  ones  are  aided  by  the 
stronger.  The  families  of  the  consumptives 
are  also  aided  by  this  means.  This  plan  re- 
sembles, in  a  way,  the  insurance  system  of 
Germany.  In  a  number  of  large  manufactur- 
ing establishments  provision  for  the  examina- 
tion of  employees  suspected  of  suffering  from 
tuberculosis,  is  made  at  the  expense  of  the  em- 
ployer, and  this  practice  is  extending. 

If  these  examples  could  be  generally  fol- 
lowed by  employers  of  labor  in  factories, 
and  the  operatives  themselves  would  co- 
operate with  the  employer  in  the  efforts 
to  protect  them  from  the  danger  of  tu- 
berculosis infection,  much  could  be  done 
in    eliminating    tuberculosis    from    the    fac- 

2.']2 


FACTORY   AND    WORKSHOP 

tory.  The  workman  will  not,  under  these 
conditions,  seek  to  conceal  his  disease  for  fear 
of  losing  his  position,  but  rather  desire  to 
avail  himself  of  the  proffered  opportunity  of 
timely  treatment.  Many  difficulties  are,  how- 
ever, encountered  in  the  ignorance  of  the 
operatives  and  their  reluctance  to  seek  an 
examination  if  they  have  suspicious  symptoms, 
or  failure  to  appreciate  the  value  to  them- 
selves or  the  dangers  to  which  they  are  expos- 
ing their  fellow-workmen.  The  general  dis- 
semination of  tuberculosis  education  through 
labor  unions,  of  which  most  workingmen 
are  now  members,  and  through  the  placards 
displayed  in  the  mills,  and  other  ways 
will  aid  in  creating  an  appreciation  of, 
and  a  response  to,  the  efforts  made  by  the 
employers  to  prevent  the  spread  of  tubercu- 
losis in  the  factory.  When  it  is  remembered 
that  one  "  open "  case  of  tuberculosis  infects 
at  least  three  others,  it  is  apparent  that  the 
only  safe  procedure  is  to  remove  every  such 
case  from  the  workshop  as  soon  as  discovered 
and  to  make  every  effort  to  discover  all  such 
cases. 

Better  Conditions  of  Factory  Life 

The   second   direction    in   which   we  must 
work  to  eliminate  tuberculosis  from  the  fac- 

273 


TUBERCULOSIS 

tory  and  mill  is  the  provision  of  a  wholesome 
environment  for  the  workman  and  protection 
from  deleterious  influences  incident  to  the 
kind  of  work  he  is  engaged  in.  Much  already 
has  been  accomplished  in  this  direction  by 
the  appreciation  of  their  responsibility  for  the 
health  and  well-being  of  their  operatives  by 
many  employers,  and  by  laws  enacted  by  en- 
lightened state  governments  regarding  the 
equipment  and  inspection  of  factories  and 
mills,  the  shortening  of  hours  of  labor,  re- 
striction of  woman  labor,  and  the  prohibition 
of  child  labor. 

The  ideal  to  be  attained  is  a  clean,  well- 
aired  and  lighted  mill,  with  room  sufficient  to 
afford  each  his  proper  air  space,  freedom 
from  dust  or  proper  apparatus  for  removing 
dust,  and  facilities  for  bathing  after  the  day's 
work.  In  addition,  opportunities  for  rest  at 
the  noon  hour,  in  a  clean,  pleasant  room,  are 
provided  by  some  employers.  What  the  state 
of  Massachusetts  requires  by  law  in  the  direc- 
tion of  the  fulfillment  of  the  above  conditions 
can,  perhaps,  be  taken  as  an  illustration  of  the 
present  attitude  of  an  enlightened  public 
opinion  with  regard  to  the  protection  of  the 
health  of  the  wage-earner. 

274 


FACTORY   AND  WORKSHOP 

First:  The  law  requires  that  all  factories 
shall  be  well  lighted,  well  ventilated  and  kept 
clean.  That  "  all  gases,  vapors,  dust  or  other 
impurities  injurious  to  health  which  are  gen- 
erated in  the  course  of  the  manufacturing 
process  or  handicraft  carried  on  therein  shall, 
so  far  as  practicable,  be  rendered  harmless." 

Second:  That  adequate  washing  and  sani- 
tary facilities  shall  be  provided. 

Third :  "  Hoods,  suction  pipes,  fans  or  blow- 
ers shall  be  provided  for  the  protection  of 
persons  using  emery  wheels  or  other  appa- 
ratus which  produces  particles  of  dust  inju- 
rious to  the  health  of  the  employee." 

Fourth :  "  Suitable  receptacles  for  expecto- 
ration shall  be  provided  in  all  factories  and 
workshops  by  the  proprietors  thereof." 

Fifth :  "  Women  employees  in  manufactur- 
ing, mechanical  or  mercantile  establishments 
shall  be  provided  with  suitable  seats  for  their 
use." 

Sixth:  The  State  Inspector  of  Health  shall 
see  that  these  various  requirements  are  carried 
out  in  factories  and  workshops,  and,  further- 
more, "  shall  inform  himself  respecting  the 
sanitary  condition  of  his  district  and  concern- 
ing  all   influences    dangerous   to   the   public 

275 


TUBERCULOSIS 

health  or  threatening  to  affect  the  same." 
"  He  shall  inform  himself  concerning  the 
health  of  all  minors  employed  in  factories 
within  his  district,  and  whenever  he  may  deem 
it  advisable  or  necessary,  he  shall  call  the  ill 
health  or  physical  unfitness  of  any  minor  to 
the  attention  of  his  or  her  parents,  or  em- 
ployers and  of  the  state  board  of  health." 
This  enactment  gives  authority  to  the  State 
Health  Inspector  to  make  a  medical  examina- 
tion of  any  person  employed  in  a  factory  be- 
tween the  ages  of  fourteen  and  twenty-one 
years,  respectively,  if,  in  his  judgment,  he 
considers  it  necessary;  and  if  he  discovers  tu- 
berculosis, he  sees,  if  possible,  that  some 
means  are  provided  for  proper  treatment. 

Mortality  from  Dusty  Trades 

Mr.  Hoffman,  the  accomplished  statistician, 
says,  in  his  report  upon  "  The  Mortality  from 
Consumption  in  Dusty  Trades,"  in  the  Bulle- 
tin of  the  Bureau  of  Labor  of  the  United 
States,  that  it  is  possible  by  intelligent  factory 
inspection  and  control,  and  special  regard  to 
ventilation,  to  almost  entirely  eliminate  condi- 
tions injurious  to  health  and  life  in  factories 
and   workshops,   and   industry   generally,    so 

276 


FACTORY   AND   WORKSHOP. 

that  the  consumption  death  rate  among  wage- 
earners  in  this  country  can  be  reduced  to  a 
ratio  as  low  as  1.5  per  1,000,  which  would 
mean  an  annual  saving  of,  approximately, 
22,238  human  lives,  and  which  would  repre- 
sent an  economic  gain  of  $68,493,000  each 
year! 

"In  New  Zealand,"  Prof.  Schrotter  tells 
us,  "  workmen  are  only  admitted  to  dusty 
occupations  after  a  special  examination,  which 
is  repeated  from  time  to  time.  Should  any 
signs  of  illness  reveal  themselves,  they  are 
immediately  dismissed."  Would  it  not  be 
wiser  to  employ  means  of  getting  rid  of  the 
dust? 

Prof.  Winslow,  of  the  Massachusetts  Insti- 
tute of  Technology,  gives  a  striking  instance 
of  "  The  Cash  Value  of  Factory  Ventilation," 
as  he  calls  it.  In  a  toll  room  of  a  telephone 
company  there  were  only  windows  at  front  and 
back  which  could  not  be,  or  were  not,  opened 
in  winter,  and,  consequently,  the  air  became 
vitiated.  At  a  cost  of  seventy-five  dollars,  a 
system  of  ventilation  was  installed,  and  fol- 
lowing this  change  there  was  a  marked  im- 
provement in  the  comfort  and  general  condi- 
tion of  the  operators.     In  the  winter  subse- 

277 


TUBERCULOSIS 

quent  to  the  installation  of  the  ventilating 
system,  the  average  percentage  of  absences 
among  sixty-odd  girls  was  reduced  one-half, 
and  in  the  three  v^inter  months  alone  the  sav- 
ing amounted  to  one  and  eight-tenths  the 
entire  time  of  one  operator,  equivalent  to  a 
profit  of  $195  for  the  company  on  a  capital 
investment  of  $75.00. 

The  Peril  of  the  Sweat  Shops 

In  the  notorious  sweat  shops  and  tenement- 
house  tailor  shops,  conditions  for  the  spread 
of  tuberculosis  are  often  well-nigh  ideal :  dust, 
dirt,  rags  and  dried  sputum  abound ;  and  yet 
we  are  told  that  the  fashionable  tailor  sends 
out  his  cut  material  to  be  made  up  in  such 
shops  and  that  the  expensive  custom-made 
suit  is  thus  manufactured  under  worse  sani- 
tary conditions  than  a  cheap  ready-made  one. 
Many  consumptives  work  in  these  shops,  and 
expectorate  on  the  floor,  thus  passing  along 
the  disease  to  their  unsuspicious  neighbor. 
The  wages  are  small,  the  hours  of  labor  long, 
and  the  surroundings  filthy  and  most  unsani- 
tary. What  more  favorable  breeding  places 
for  tuberculosis  could  be  conceived !  Seed  in 
plenty  and  the  conditions  are  present  for  the 
constant  manufacture   of  a   fertile   soil.     A 

278 


FACTORY   AND  WORKSHOP 

single  example  from  the  observations  of  the 
state  medical  inspector  of  Boston,  Dr.  Linen- 
thai,  will  vividly  show  us  how  the  process 
takes  place.  A  two-room  flat  on  the  top  of  a 
building,  situated  in  a  narrow,  dirty  street; 
three  persons  living  in  these  rooms, — a  young 
man  of  twenty-five  with  his  mother  and 
grandmother.  The  two  women  finished  pants 
at  home,  their  only  means  of  subsistence;  the 
young  man  a  consumptive  and  unable  to  work. 
A  small,  low-studded  room,  used  as  a  kitchen 
and  workroom,  served  at  night  as  a  bed-room 
for  the  consumptive;  the  windows  closed,  a 
kerosene  stove  burning,  the  young  consump- 
tive remaining  at  home  all  day  in  this  suffo- 
cating air. 

"  The  inadequate  rate  of  wages,"  says  Dr. 
Linenthal,  "  the  excessive  hours  of  labor,  the 
unsanitary  state  of  the  shops,  make  of  our 
clothing  industry  a  sweating  industry,  with  all 
the  predisposing  factors  of  tuberculosis  in 
full  operation."  The  root  of  the  evil,  he  de- 
clares, is  the  contract  system, — the  manufac- 
turer handing  over  the  cut  material  to  the 
contractor,  who,  in  consequence  of  the  close 
competition,  makes  the  goods  for  a  small 
compensation. 

The  remedy  is  public  knowledge  of  the  ex- 
279 


TUBERCULOSIS 

isting  conditions  and  a  demand  for  clean 
clothing.  The  sweat  shop,  as  such,  ought  no 
longer  to  exist,  for  it  is  a  hot-bed  for  breeding 
tuberculosis.  So  long,  however,  as  it  does,  it 
must  be  rigidly  inspected  and  kept  under  con- 
stant supervision,  and  when  a  consumptive  is 
discovered  in  such  places,  he  should  be  re- 
moved. The  dirty,  ignorant,  newly  arrived 
immigrant,  the  sweat  shop,  and  the  crowded 
tenement,  form  a  combination  admirably 
fitted  to  spread  tuberculosis.  This  combina- 
tion can  be  broken,  however,  by  arousing 
public  opinion,  by  an  efficient  active  board  of 
health  and  strict  and  adequate  tenement- 
house  inspection. 

The  Remedy  for  Dust  in  Factories 

Reference  has  already  been  made  to  the 
heavy  mortality  from  consumption  among  per- 
sons occupied  in  dusty  trades,  and  there  are 
but  few  in  which  dust  is  not  given  off.  Many 
investigators  have  studied  the  conditions,  and 
the  general  conclusion  is  that  the  one  universal 
and  effective  remedy  is  ventilation :  to  remove 
the  dust  at  its  point  of  origin,  and  insure  an 
abundant  supply  of  fresh  air.  That  this  is 
both  practicable  and  possible  at  moderate  ex- 

280 


FACTORY   AND  WORKSHOP 

pense,  has  been  shown  by  an  English  com- 
mittee appointed  to  inquire  into  the  ventilation 
of  factories  and  workshops.  It  seems  almost 
incredible  that  the  needless  and  enormous  loss 
of  human  life  from  consumption  due  to  dust 
in  industrial  pursuits  and  the  financial  loss 
incurred  therefrom,  as  shown  above,  should 
be  allowed  to  go  on.  "  Nothing  within  rea- 
son," says  Mr.  Hoffman,  "  should  be  left 
undone  as  a  national,  state,  and  individual,  or 
social,  duty  to  prevent  it,"  and  yet,  he  con- 
cludes, "  thus  far  the  problem  of  scientific 
ventilation  and  effective  dust  removal  has  been 
almost  entirely  neglected  in  American  estab- 
lishments." 

In  this  age  of  industrialism  and  the  eager 
strife  for  immediate  and  large  pecuniary  re- 
sults, human  life,  of  inestimable  value,  is 
often  lightly  held  and  needlessly  sacrificed 
on  the  altar  of  gain.  The  most  valuable  asset 
of  any  country  is  men  and  women  of  healthy, 
robust  physique,  and  when,  in  its  develop- 
ment, these  are  sacrificed,  the  decline  and  fall 
of  that  country  in  no  distant  future  can  be 
predicted,  as  the  history  of  the  past  has 
shown. 


281 


TUBERCULOSIS 

Department  Stores  and  Shops 

In  department  stores  and  shops,  there  are 
all  too  frequently  rich  opportunities  for  the 
preparation  of  the  favorable  soil  for  the  tuber- 
culous infection.  A  bookkeeper  or  clerk  is 
often  tucked  away  in  a  gallery,  or  a  corner, 
breathing  the  hot,  vile  air  from  the  floor  be- 
low, contaminated  with  dust  and  nobody 
knows  how  many  infectious  germs.  Great 
department  stores  are  often  most  inade- 
quately ventilated  and  lighted  and  over- 
crowded. How  many  young  lives  are  thus 
lost  from  consumption,  the  favorable  soil  for 
which  was  prepared  in  this  way.  Some  de- 
partment stores  are  already  realizing  their 
obligations  to  their  employees,  and  provide  a 
physician  to  look  after  their  health  in  a  gen- 
eral way.  What  should  be  done,  however, 
and  the  writer  ventures  to  predict  that  the 
time  is  coming  when  it  will  be  done,  is  to 
examine  the  lungs  of  every  clerk  and  em- 
ployee in  such  establishments  upon  their 
entrance  into  the  employ  of  the  firm,  and 
periodically  thereafter. 

Waiters,  Nurse  Girls  and  Servants 

The  same  precaution  ought  also  to  be  taken 
with  regard  to  waiterr  in  hotels,  who,  in  the 
writer's    experience,    have    not    infrequently 

282 


FACTORY   AND    WORKSHOP 

been  found  to  be  tuberculous,  for  in  the  han- 
dling of  the  food  and  the  intimate  associations 
with  so  many  others,  the  opportunities  for 
communicating  the  disease  are  great.  Again, 
with  nursery  maids,  cooks,  and  servants  in 
private  houses,  this  also  should  be  done.  How 
much  better  to  find  out  that  tuberculosis  exists 
in  such  persons  before  their  employment  in 
the  household  than  later,  when  the  children 
and  family  have  been  exposed  to  the  disease ; 
and  this  is  no  imaginary  fear, — it  has  hap- 
pened not  infrequently.  No  one  desires  to 
employ  in  the  family  a  person  who  has  not 
been  vaccinated.  Every  school  child  is  obliged 
to  present  a  certificate  of  vaccination  upon 
entrance  to  the  school.  Is  it  not  at  least 
equally  important  to  require  evidence  of  ab- 
sence of  tuberculosis  in  servant  and  pupil, 
when  we  consider  the  enormous  prevalence 
of  the  latter,  and  the  infrequency  of  small- 
pox? 

Tuberculosis  in  Prisons 

In  former  years  tuberculosis  was  very 
prevalent  in  prisons,  so  much  so  that  it  was 
regarded  as  a  disease  peculiar  to  these  insti- 
tutions and  called  "  prison  tuberculosis." 
Thus  as  late  as  1893,  a  report  from  the  Illinois 
State  Prison  says  that  fully  one-third  of  the 

283 


TUBERCULOSIS 

1,400  convicts  within  its  walls  have  consump- 
tion in  a  light  or  bad  form ;  and  that  nearly  all 
deaths  in  the  penitentiary  are  caused  by  con- 
sumption. All  "  long  timers "  as  a  rule,  it 
continues,  "  either  die  within  the  walls  from 
the  disease  or  are  pardoned  out  on  account 
of  it." 

The  cause  is  very  evident,  for  the  prisons 
were  crowded,  and  little  if  any  attention  was 
paid  to  the  sanitary  conditions  and  ventilation, 
and  the  tuberculous  inmates  mingled  freely 
with  the  others  and  expectorated  at  random. 
In  part,  this  condition  was  due  to  the  igno- 
rance of  the  communicability  of  tuberculosis, 
and  in  part  to  the  old  idea  that  the  prisoner 
was  there  to  be  punished,  not  to  be  reformed, 
and  the  protection  of  his  health  and  the  pro- 
vision of  wholesome  conditions  of  living  re- 
ceived but  secondary  consideration. 

At  the  present  time  many  prisons  and  jails 
are  still  conducted  upon  the  old  ideas  and  are 
woefully  defective  in  proper  hygienic  con- 
struction and  equipment.  It  is  estimated  that 
about  15  per  cent,  of  the  prison  population 
of  the  country  at  the  present  time  is  suf- 
fering from  tuberculosis.  The  tuberculosis 
Crusade,  however,  has  invaded  the  penal  in- 
stitutions, and  both  direct  and  indirect  means 
are  being  employed  in  many  prisons  to  protect 

284 


FACTORY   AND   WORKSHOP 

the  well  inmates  from  exposures  to  infection 
and  to  treat  the  tuberculous  ones  by  the  mod- 
ern methods  of  out-door  life  and  good 
hygiene.  Prison  workshops  are  better  venti- 
lated and  cleaner,  cells  are  larger  and  are 
supplied  with  suitable  means  of  ventilation 
and  more  light,  and  are  kept  clean.  The 
physical  care  of  the  prisoner  is  given  more 
careful  attention  in  the  matter  of  bathing, 
food  and  exercise.  The  new  humane  idea  is 
now  gaining  ground  that  the  prisoner  is  a 
human  being  with  a  soul,  and  not  a  brute,  and 
as  such  should  receive  such  physical  and 
moral  training  as  will  incite  him  to  reform  and 
not  to  sink  deeper  in  degradation.  As  a  part 
of  the  responsibility  of  the  state  towards  the 
prisoner,  is  his  protection  from  exposure  to 
tuberculosis  while  in  captivity. 

In  a  number  of  states  tuberculosis  prisoners 
are  now  afforded  opportunity  for  taking  the 
open-air  treatment  and  are  separated  from  the 
other  inmates  in  order  to  avoid  the  possibility 
of  communicating  the  disease  to  them.  In 
Massachusetts  a  prison  hospital  or  sanatorium 
has  been  established  at  Rutland  not  far  from 
the  State  Sanatorium,  to  which  all  consump- 
tive prisoners  from  the  various  prisons  and 
jails  of  the  state  are  transferred.  At  Clinton 
Prison,  New  York,  in  the  Adirondack  Moun- 

285 


TUBERCULOSIS 

tains,  there  are  special  wards  for  the  tuber- 
culous prisoners  of  that  state.  In  Texas  is  a 
state  farm  for  the  same  purpose  where  the 
consumptive  prisoners  who  are  able  to  work 
are  employed  in  light  farm  work,  gardening, 
etc.  Previous  to  the  use  of  this  farm,  says 
Dr.  Ransome,  50  per  cent,  of  all  the  deaths  in 
the  prisons  of  the  state  of  Texas  were  due  to 
tuberculosis,  while  during  the  three  years  of 
existence  of  the  farm  the  total  number  of 
deaths  in  prisoners  from  this  disease  was  a 
little  less  than  25  per  cent.  Much,  however, 
remains  to  be  done,  for  there  are  now  less  than 
25  special  institutions  and  hardly  800  beds  for 
the  12,000  tuberculous  prisoners  in  the  state, 
federal  and  local  prisons  and  jails  of  the 
United  States. 

Tuberculosis  in  Insane  Asylums 

Formerly  tuberculosis  was  as  prevalent  in 
insane  asylums  as  in  prisons,  and  from  very 
much  the  same  causes.  No  effort  was  made 
to  control  the  insane  consumptive,  and  thus  he 
infected  others,  while  overcrowding  and  lack 
of  ventilation  readily  prepared  the  soil  in  those 
who  were  already  in  a  defective  physical  con- 
dition, as  most  insane  persons  are.  Fifty 
years  ago  in  one  insane  hospital  in  Massachu- 

286 


FACTORY   AND    WORKSHOP 

setts,  33  per  cent,  of  the  deaths  in  one  year 
were  due  to  tuberculosis,  and  at  the  present 
time  the  percentage  of  deaths  from  tuberculo- 
sis among  the  insane  is  from  50  to  200  per 
cent,  higher  than  among  the  general  popula- 
tion according  to  the  institution.  At  the 
present  time  the  consumptive  insane  are  seg- 
regated, and  in  many  states  provision  is  made 
for  giving  them  the  open-air  treatment.  The 
result  of  this  has  been  a  reduction  of  mortality 
from  tuberculosis.  Thus,  in  1900,  the  aver- 
age mortality  in  all  the  New  England  insane 
hospitals  was  11.9  per  cent.  The  general  im- 
provement in  the  care  of  the  insane,  and  in 
the  construction  and  ventilation  of  asylums, 
has  also  contributed  to  the  lessened  mortality 
from  tuberculosis.  Yet  the  fact  remains  that 
out  of  225  public  hospitals  for  the  insane  with 
a  population  of  fully  150,000,  only  70  or  less 
than  one-third  of  them  make  any  provision  for 
their  tuberculous  inmates.  So  the  great 
Crusade  against  tuberculosis  permeates,  in  its 
beneficent  influences,  the  prison  and  the  asy- 
lum, the  workshop  and  factory,  with  its  mes- 
sage of  hope;  and  if  it  does  not  always  bring 
healing  on  its  wings  for  the  afflicted,  it  tells 
him  how  he  can  avoid  infecting  others,  and 
by  its  gospel  of  fresh  air  and  good  hygiene,  it 
shows  how  best  the  disease  can  be  resisted. 

287 


XV.     THE  FUTURE  OUTLOOK 

^^-.— -^^E  have  come  at  last  nearly  to  the 
^  ■  ^^  end  of  the  story  of  the  Great 
V  I  V  White  Plague,  a  story  that  has 
^^^^^^  i^ot  been  all  sadness  in  the  telling, 
.but  rather  illuminated  with  great 
hope  for  the  future.  We  have  seen  in  our 
narrative  that  tuberculosis  is  a  universal  and 
very  prevalent  disease,  affecting  mankind  at 
the  most  valuable  period  of  life;  that  it  is  a 
contagious  or  communicable  disease,  the  cause 
of  which  we  know ;  and  that  it  is  not  inherited. 
We  have  learned  that  it  requires  a  favorable 
soil  in  the  body  to  produce  the  active  disease, 
and  we  have  seen  how  innumerable  are  the  in- 
fluences which  produce  this  favorable  soil. 
We  have  found  that  it  is  very  curable  if  taken 
in  the  beginning,  and  that  the  cure  is  not 
by  medicines,  but  by  open-air  treatment,  the 
method  of  which,  as  conducted  in  a  sanato- 
rium or  at  home,  we  have  learned.  We  have 
studied  the  means  of  prevention,  both  by  con- 

288 


THE   FUTURE   OUTLOOK 

trolling  the  source  of  infection  and  by  render- 
ing the  soil  unfavorable.  The  social  condi- 
tions which  are  favorable  for  the  spread  of 
the  disease  have  been  considered,  with  their 
remedy,  and  among  them  we  have  seen  that 
overcrowding  in  in-door  life,  bad  air,  and  the 
abuse  of  alcohol  are  three  of  the  most  fre- 
quent predisposing  causes.  Again,  we  have 
learned  that  tuberculosis  is  frequent  in  child- 
hood, and  the  various  means  employed  in  dif- 
ferent countries  to  protect  the  child  from 
contracting  the  disease,  and  to  cure  it  when 
affected,  have  been  considered.  In  the  great 
crusade  against  tuberculosis,  we  have  seen 
what  the  weapons  and  methods  are  which  the 
various  countries  of  the  world  are  using  in 
the  warfare;  how  the  educational  propaganda 
has  extended  until  the  simple  facts  regarding 
the  disease  are  becoming  almost  as  univer- 
sally disseminated  as  the  waters  which  cover 
the  seas. 

When  we  consider  in  detail  the  means  of 
prevention,  they  seem  almost  hopelessly  many 
and  complicated,  but  the  great  principles, 
after  all,  are  few  and  simple :  to  find  out  every 
consumptive;  to  render  safe  or  isolate  every 
consumptive;  and  to  improve  the  living  con- 

289 


TUBERCULOSIS 

dition  of  the  masses.  It  is  controllino  the 
seed  and  rendering  the  soil  infertile.  As 
gigantic  a  task  as  this  is,  it  can  be  done  and 
is  already  in  the  process  of  accomplishment. 

Resolutions  of  the  International  Congress 

In  this  connection  it  will  be  well  to  give 
the  resolutions  of  the  International  Congress 
at  Washington,  as  indicating  the  future  most 
important  lines  of  effort  in  the  opinion  of  the 
best  authorities  throughout  the  world.  They 
are  as  follows: 

"  I.  The  attention  of  state  and  central  gov- 
ernments should  be  called  to  the  importance 
of  proper  laws  for  the  obligatory  notification 
by  medical  attendants  to  proper  health  authori- 
ties of  all  cases  of  tuberculosis  coming  to  their 
notice,  and  for  the  registration  of  such  cases 
in  order  to  enable  the  health  authorities  to 
put  into  operation  adequate  measures  for  the 
prevention  of  the  disease.  We  urge  on  the 
public  and  on  all  governments  the  establish- 
ment of  hospitals  for  the  treatment  of  ad- 
vanced cases  of  tuberculosis. 

"  2.  We  urge  the  establishment  of  sanatoria 
for  curable  cases  of  tuberculosis. 

"  3.    We  urge  the  establishment  of  dispen- 
290 


THE    FUTURE   OUTLOOK 

saries  and  day  camps  for  ambulant  cases  of 
tuberculosis  which  cannot  enter  hospitals  or 
sanatoria.  Again  the  utmost  efforts  should  be 
continued  in  the  struggle  against  tuberculosis 
to  prevent  conveyance  from  man  to  man  of 
tuberculous  infection  as  the  most  important 
source  of  the  disease.  Further  preventive 
measures  must  be  continued  against  bovine 
tuberculosis,  and  the  possibility  of  the  propa- 
gation from  this  to  man  should  be  recognized. 
"Resolved,  That  this  Congress  indorse 
such  well-considered  legislation  for  the  regu- 
lation of  factories  and  workshops,  the  aboli- 
tion of  premature  and  injurious  labor  to 
women  and  children,  and  the  securing  of 
sanitary  dwellings  as  will  increase  the  resist- 
ing power  of  the  individual  to  tuberculosis 
and  other  diseases ;  that  instruction  in  personal 
and  school  hygiene  should  be  given  in  all 
schools  for  the  professional  training  of  teach- 
ers ;  that  wherever  possible  such  instruction  in 
elementary  hygiene  should  be  entrusted  to 
properly  qualified  medical  instructors;  that 
colleges  and  universities  should  be  urged  to 
estabHsh  courses  in  hygiene  and  sanitation, 
and  also  to  include  these  subjects  among  their 
entrance  requirements  to  stimulate  useful  ele- 

291 


.TUBERCULOSIS 

mentary  instruction  in  the  lower  schools.  That 
this  Congress  indorses  and  recommends  the 
establishment  of  playgrounds  as  an  important 
means  of  preventing  tuberculosis  through 
their  influence  on  health  and  resistance  to 
disease." 

A  Look  Forward 

In  conclusion,  we  are  now  in  a  position  to 
look  forward,  and  from  what  has  already  been 
gained,  with  some  degree  of  definiteness,  fore- 
cast the  future.  We  ask  what  will  be  the  final 
result  of  this  mighty  movement?  Can  we 
ultimately,  within  an  appreciable  period  of 
time,  eliminate  tuberculosis  so  that  it  will  be- 
come as  rare  as  leprosy,  for  example,  now  is? 
Shall  we  at  last  free  mankind  from  this  its 
inveterate  foe?  Theoretically,  we  know  we 
can,  for  we  have  learned  that  tuberculosis  is 
a  preventable  and  avoidable  disease ;  but  can 
this  practically  be  accomplished? 

Those  who  have  been  .the  leaders  in  the 
great  campaign  believe  that  it  can,  as  hercu- 
lean as  the  task  seems  to  be;  and  what  has 
already  been  gained  in  the  diminution  of  the 
disease  is  strong  evidence  in  support  of  this 
opinion.   "  I  believe,"  says  Dr.  Biggs,  the  ac- 

292 


THE   FUTURE   OUTLOOK 

complished  medical  officer  of  the  New  York 
Health  Department,  "  that  tuberculosis  can  be 
practically  stamped  out,"  and  in  support  of 
this  opinion  he  says  that  the  reduction  in  the 
mortality  from  it  in  New  York  City  since  1886 
has  been  about  40  per  cent.    "  I  certainly  be- 
heve,"  said  Prof.  Vaughan,  of  the  University 
of  Michigan,  in  an  address  at  the  Tubercu- 
losis Congress  at  Washington,  "  that  the  time 
will  come  when  tuberculosis  will  no  longer 
curse  our  race."     "  We  see  then,"  says  Prof. 
Irving    Fisher,    "  that    the    modern    Crusade 
against  consumption  means  more  than  appears 
on  the  surface.    It  means,  to  be  sure,  the  sav- 
ing of  the  lives  of  many  afflicted  with  the 
*  Great  White  Plague,'  but  it  means,  further, 
a  continual  lessening  in  the  numbers  thus  af- 
flicted   ...    it  means  that  tuberculosis  will 
soon  be  dethroned  from  its  position  as  chief 
of    the    diseases,    and    ultimately    eradicated 
altogether."    "  If  every  individual  in  his  re- 
spective sphere,  and  the  local  state  and  Fed- 
eral governments   would  do   his   full   duty," 
says  Dr.  Knopf,  "  in  the  combat  of  this  fear- 
ful scourge  of  mankind,  so  justly  called  the 
'  Great  White  Plague,'  I  am  convinced  that 
before  many  decades  tuberculosis  would  be 

293 


TUBERCULOSIS 

eradicated  from  our  midst."  "  The  Germans 
now  look  forward,"  quotes  Prof.  Lowman 
from  a  German  authority,  "  with  increasing 
confidence,  to  a  new  future,  to  a  new  golden 
age,  when  there  will  be  a  Germany  without 
tuberculosis."  "  We  may  reasonably  prophesy," 
declared  Prof.  Brouardel  of  Paris,  at  the 
British  Congress  on  Tuberculosis,  "  that, 
united  in  one  brave  attempt,  the  whole  civil- 
ized world  will  succeed  in  exterminating  the 
cruelest  scourge  that  has  ever  fallen  on  us, 
our  children  and  our  friends,  and  which 
threatens  the  future  of  our  countries." 

At  the  same  Congress  Prof.  Koch,  in  his 
memorable  address,  spoke  as  follows :  "  There 
are  many,  indeed,  who  doubt  the  possibility 
of  successfully  controlling  this  disease,  which 
has  existed  for  thousands  of  years,  and  has 
spread  all  over  the  world.  This  is  by  no 
means  my  opinion.  This  is  a  conflict  into 
which  we  may  enter  with  a  surely  founded 
prospect  of  success.  .  .  .  This  is  a  visible 
and  palpable  enemy  which  we  can  pursue  and 
annihilate,  just  as  we  can  pursue  and  annihi- 
late other  parasitic  enemies  of  mankind." 

"  Science  has  demonstrated,"  said  former 
President  Roosevelt  in  his  letter  accepting  the 

294 


THE  FUTURE  OUTLOOK 

presidency  of  the  International  Congress  on 
Tuberculosis,  "  that  this  disease  can  be 
stamped  out,  but  the  rapidity  and  complete- 
ness with  which  this  can  be  accomplished  de- 
pend upon  the  promptness  with  which  the  new 
doctrines  about  tuberculosis  can  be  inculcated 
into  the  minds  of  the  people  and  engrafted 
upon  our  customs,  habits  and  laws." 

Twelve  years  ago  the  writer  of  this  book 
made  the  following  statement,  which,  with 
our  present  knowledge  and  experience,  he 
feels  could  be  made  even  more  emphatic :  "  I 
firmly  believe  that  it  is  possible,  by  a  union  of 
all  the  resources  at  hand — state  and  law,  in- 
dividual and  organized  exertions,  enlighten- 
ment of  the  public  as  to  the  dangers  of  the 
dried  sputum  and  their  avoidance,  and  the 
utilization  of  all  the  means  at  our  command  to 
increase  the  general  average  of  health — so  to 
reduce  the  mortality  from  consumption  that 
it  may  become  one  of  the  rarer  diseases  in- 
stead of  the  most  common  as  now." 

Some    Statistics    of    the    Diminution    of    Tuber- 
culosis 

The  statistics  already  at  hand  of  the  gen- 
eral diminution  of  deaths   from  tuberculosis 

295 


TUBERCULOSIS 

bring  the  same  message  of  hope  for  the  future 
extermination  of  the  disease.  According  to 
carefully  collected  statistical  evidence,  Mr. 
Hoffman,  the  statistician  of  the  Prudential  In- 
surance Company,  shows  that  in  the  decade 
from  1901  to  1910  the  death  rate  from  tuber- 
culosis of  the  lungs  in  the  United  States  (the 
registration  area)  decreased  18.7  per  cent., 
while  the  general  death  rate,  including  all 
causes  of  death,  declined  only  one-half  as  fast. 
This  decline  in  the  tuberculosis  death  rate 
means  the  saving  of  27,000  lives.  In  the 
Northern  and  Western  cities  of  the  United 
States  the  death  rate  from  tuberculosis  of  the 
lungs  has  declined  since  1881  from  325  to  160 
per  100,000  inhabitants,  or  50.8  per  cent.  In 
the  Southern  cities  there  has  been  a  decline  of 
50.2  per  cent,  for  the  whites,  and  36.7  per  cent. 
for  the  colored  population  since  1881. 

In  the  three  industrial  Eastern  states, 
Massachusetts,  Rhode  Island  and  Connecticut, 
with  a  population  of  over  5,153,000,  from  1881 
to  191 1,  the  decline  has  been  from  293  in  1881 
to  128  in  191 1  per  100,000  inhabitants,  or  56.3 
per  cent.  In  the  cities  of  New  York  (Man- 
hattan and  Bronx),  Philadelphia  and  Boston 
combined,  the  decline  from  1881  to  1912  has 
been  from  381. i  to  180.1  per  100,000  of  pop- 

296 


THE    FUTURE    OUTLOOI 


v 


ulation,  or  52.7  per  cent. ;  while  in  the  cities 
of  New  York  (Manhattan  and  Bronx),  Phila- 
delphia and  Boston  singly,  the  decrease  from 
1 88 1  to  191 2  has  been,  respectively : — 53.7  per 
cent.,  New  York ;  48.7  per  cent.,  Philadelphia ; 
and  6;^.2  per  cent.,  Boston,  and  in  the  latter 
city  the  rate  has  dropped  in  twelve  years  from 
250  per  100,000  to  146,  or  42  per  cent.  In 
Massachusetts  the  death  rate  from  consump- 
tion has  been  reduced  one-half  in  the  last 
twenty  years. 

"  All  the  evidence  obtainable,''  says  Mr. 
Hoffman,  "  confirms  the  conclusion  that  the 
reduction  of  the  tuberculosis  death  rate  in  the 
United  States  during  the  last  forty  years  has 
not  been  less,  but  in  many  cases  much  more 
than  in  other  civilized  countries  throughout 
the  world."  In  England  and  Wales  there  has 
been  a  reduction  of  43.7  per  cent,  in  the  last 
thirty  years.  In  large  German  cities,  from 
1880  to  1909,  the  death  rate  from  tuberculosis 
has  decreased  from  346  per  100,000  of  popula- 
tion to  179,  or  48.2  per  cent.,  while  in  Amer- 
ican cities  during  the  same  period  the  decrease 
has  been  42.3  per  cent.  This  difference  in 
favor  of  German  cities  is  attributed  by  Mr. 
Hoffman  to  "  the  systematic  and  effective 
treatment  and  care  of  tuberculous  wage  earn- 

297 


TUBERCULOSIS 

ers  in  special  institutions  or  sanatoria  estab- 
lished for  the  purpose,  and  many  collateral  in- 
stitutions and  efforts  contributory  thereto." 

Similar  diminution  in  the  death  rate  from 
tuberculosis  is  taking  place,  to  a  greater  or  less 
extent,  in  all  countries  and  cities  of  the  civil- 
ized world,  as  their  various  statistics  indicate ; 
but  enough  has  been  given  to  prove  the  success 
of  the  great  v^arfare  against  the  disease,  and  to 
give  every  hope  for  a  continued  gradual  de- 
crease until  the  disease  becomes  practically 
eliminated.  "  At  the  present  rate  of  decrease 
in  the  mortality  from  consumption,"  said  Dr. 
Abbot,  the  late  secretary  of  the  Massachusetts 
State  Board  of  Health,  "  it  does  not  seem  at 
all  impossible  that,  within  the  next  half  cen- 
tury, the  sanatoria  now  occupied  by  consump- 
tives may  possibly  be  filled  by  those  suffering 
from  cancer,  since  cancer  appears  to  be  stead- 
ily increasing  while  consumption  is  tending 
towards  extinction."  We  have  already  seen 
how  the  leper  hospitals  in  Norway  have  been 
converted  into  sanatoria  for  tuberculosis,  now 
that  leprosy  has  been  practically  extinguished. 

"  The  real  triumph  of  the  campaign  against 
tuberculosis,"  as  Mr.  Hoffman  so  justly  con- 
cludes, ''  is  the  human  factor,  representing,  on 
the  one  hand,  the  faith  and  work  of  those  who, 

298 


THE    FUTURE   OUTLOOK 

by  intelligent  co-operation  and  indefatigable 
industry,  have  reduced  the  warfare  against 
this  disease  to  a  science,  and,  on  the  other,  the 
immeasurable  amount  of  human  happiness 
brought  to  the  countless  homes  and  hearts  of 
those  who,  but  for  the  success  which  has  been 
achieved,  would  have  had  only  sorrow  and 
suffering,  and  who  would  have  faced  the  fu- 
ture in  helpless  despair." 

The  Advance  in  the  Future 

It  is  probable  that  from  this  time  on,  the 
diminution  will  be  slower  than  it  has  been  in 
the  past,  for  we  have  already  partially  cor- 
rected many  of  the  grosser  causes  of  the 
former  prevalence  of  the  disease,  such  as  re- 
striction of  indiscriminate  spitting,  the  control 
of  the  advanced  consumptive,  the  protection 
of  his  family,  many  of  the  social  conditions 
which  predispose  to  this  disease,  etc.  In  the 
future,  our  work  must  be  more  intensive,  com- 
prehensive, and  systematic.  "  It  is  not  a 
very  difficult  problem,"  to  quote  Mr.  Hoffman 
again,  "  to  reduce  an  excessive  death  rate  to 
one  of  moderate  proportions,  but  it  requires 
the  highest  skill  in  sanitary  administration. 
Using  that  term  in  its  broadest  sense,  consid- 
erably to  reduce  a  low  death  rate  still  further, 

299 


TUBERCULOSIS 

and  most  of  all  in  the  case  of  so  subtile  and 
widely  diffused  disease  as  tuberculosis."  We 
must  work  harder,  and  have  a  great  deal  more 
money  to  work  with.  "  The  time  is  not  far 
distant,"  said  Dr.  Biggs  in  1903,  "  when  those 
states  and  municipalities  which  have  not 
adopted  a  comprehensive  plan  for  dealing  with 
tuberculosis  will  be  regarded  as  almost  crim- 
inally negligent  in  their  administration  of  sani- 
tary affairs  and  inexcusably  blind  to  their 
own  best  economic  interests."  In  the  great  ad- 
vances made  in  the  early  detection  of  consump- 
tion and  the  consequent  timely  treatment,  there 
is  and  will  be  increasingly  in  the  future  the 
greatest  assurance  that  the  individual  who  has 
the  disease  will  recover;  and  what  a  contrast 
this  hopeful  outlook  is  to  the  former  hopeless 
attitude!  Furthermore^  the  various  methods 
of  home  treatment  now  being  extended  and 
generally  adopted  and  this  increase  of  state 
sanatoria  bring  the  opportunities  of  success- 
ful treatment  within  the  means  of  the  poorest. 

The  Open-Air  School  in  the  Future 

We  have  spoken  of  the  open-air  schools  for 
"  closed "  cases  of  tuberculosis  in  children. 
Their  value  as  a  curative  and  preventive 
measure   has   been    so    clearly    demonstrated 

300 


r   ^ 


THE    FUTURE    OUTLOOK 

that  one  can  predict  with  great  assurance 
that  in  the  future  they  will  be  established 
in  all  large  cities  as  they  already  have  been 
in  nearly  50  cities,  and  thereby  thousands 
of  tuberculous  children  will  be  cured  and 
grow  up  to  make  their  contributions  in  va- 
rious channels  of  useful  effort  to  the  com- 
munities in  which  they  live.  Nothing  is  more 
hopeful  and  encouraging  than  this  work 
with  tuberculous  children,  which,  in  the  fu- 
ture, is  destined  to  become  a  great  and 
important  feature  of  the  tuberculosis  cam- 
paign. 

Influence  of  This  Movement  in   Preventing 
Other  Diseases 

This  great  tuberculosis  movement  has  been 
of  incalculable  value  in  exciting  effort  for  the 
prevention  of  other  diseases  and  conditions 
inimical  to  health,  and  as  time  goes  on,  we 
shall  see  the  results  of  its  influence  in  this 
direction  more  definitely.  Already  there  is  a 
marked  uplift  in  the  living  and  working  con- 
ditions of  the  masses,  but  it  is  just  a  begin- 
ning. The  gospel  of  fresh  air  has  never  been 
so  universally  proclaimed  as  it  is  to-day 
through  the  influence  of  the  tuberculosis 
movement.  A  new  and  mighty  impulse  has 
been  set  in  motion,  looking  towards  preven- 

301 


TUBERCULOSIS 

tion,  due  in  no  small  measure  to  the  tuber- 
culosis crusade.  As  President  Eliot  has  re- 
cently told  us,  the  doctors  of  the  future  are 
to  be  chiefly  occupied  in  the  prevention  of 
disease,  and  already  the  medical  schools  are 
teaching  preventive  medicine.  May  we  not 
look  forward  to  a  new  era  in  civilization  when 
our  efforts  shall  not  be  exerted  so  much,  as  in 
the  past,  in  establishing  elaborate  and  expen- 
sive institutions  for  the  treatment  and  re- 
straint of  those  physically  or  morally  diseased, 
but  rather  for  the  prevention  of  those  condi- 
tions which  make  these  necessary,  the  preven- 
tion of  disease,  poverty  and  crime.  We  can 
well  repeat  the  significant  words  of  Mr.  Casi- 
mir  Perier :  "  The  struggle  against  tuber- 
culosis is  intimately  bound  up  with  the  solu- 
tion of  the  most  complex  economic  problems, 
and  any  plan  will  be  imperfect  which  has  not 
for  its  foundation  the  material  and  moral  im- 
provement of  the  people." 

Another  Influence  —  Peace  Between  Nations 

One  of  the  great  incidental  values  of  the 
world-wide  Crusade  against  tuberculosis  is 
the  fraternal  feeling  engendered  by  the  union 
of  all  nations  and  peoples  for  the  common  pur- 

302 


THE    FUTURE    OUTLOOK 

pose  of  preventing  and  eliminating  this  com- 
mon enemy  of  mankind.  This  is  impressively 
emphasized  at  the  International  Congresses 
on  Tuberculosis  such  as  the  one  held  in  Wash- 
ington in  1908  and  in  Rome  in  1912,  where 
are  gathered  physicians,  sanitarians,  philan- 
thropists and  men  and  women  engaged  in  the 
great  conflict  from  all  over  the  world,  repre- 
senting various  forms  of  governments,  and 
speaking  many  tongues,  but  all  with  the  kind- 
liest feelings,  one  towards  another,  because 
they  were  united  by  the  one  single  beneficent 
object  of  stamping  out  tuberculosis. 

May  we  not  hope  that  this  universal  union 
for  a  common  purpose  may  have  a  definite 
and  real  influence  in  uniting  nations  closer 
together,  and  create  a  deeper  realization  of 
the  value  to  each  of  the  union  of  all  in  efforts 
to  stamp  out  disease  and  thereby  increase  the 
welfare  and  happiness  of  mankind.  May  not 
this  influence  be  of  value  in  promoting  peace 
between  nations,  and  ultimately  lead  to  a  more 
enlightened  attitude  with  regard  to  the  present 
enormous  expenditures  for  war  preparations, 
and  a  mutual  agreement  to  limit,  in  the  future, 
such  preparations  for  the  destruction  of  life 
and  property,  and  to  increase  their  efforts  and 

303 


TUBERCULOSIS 

appropriations  for  the  preservation  of  life  and 
the  prevention  of  disease. 

No  one  v^^ould  dare  predict  the  rapidity 
with  which  tuberculosis  could  be  eliminated 
if  even  a  portion  of  the  annual  appropriation 
made  for  military  purposes  could  be  em- 
ployed in  the  warfare  against  it.  We  may 
confidently  hope  that  this  grand  movement 
which  has  taken  possession  of  the  whole  civ- 
ilized world  will,  in  the  future,  accomplish 
more  than  even  the  eradication  of  tubercu- 
losis,— that  it  will  bring  together,  in  friendly 
rivalry  to  increase  the  well-being  of  humanity, 
the  nations  of  the  world,  promote  peace  be- 
tween them  and  put  an  end  to  the  present 
feverish  haste  to  build  up  huge  armaments, 
and  turn  the  efforts  of  the  governments  into 
peaceful  and  beneficent  channels  for  the  pro- 
tection of  the  health  of  their  people  and  the 
increase  of  their  happiness. 


304 


CHAPTER    XVI.      THE    LUNGS    AND 
THEIR  USE 

E  have  learned  that  nearly  nine- 
tenths  of  all  cases  of  tuberculosis 
are  of  the  lungs — consumption — 
and  it  is,  therefore,  of  the  highest 
importance  to  have  some  clear 
knowledge  of  the  function  and  proper  use  of 
these  organs, — we  should  know  something  of 
their  anatomy,  what  service  they  perform, 
how  to  use  them,  how  to  maintain  them  in 
their  integrity,  and  what  injurious  influences 
to  avoid.  If  one  were  to  ask  a  young  school 
boy  what  the  lungs  were  for,  he  would  un- 
doubtedly promptly  reply,  "  To  breathe  with," 
and  if  he  should  then  be  asked,  "  Why  do  we 
breathe  ? "  he  would  again  as  readily  reply, 
"  If  we  didn't  breathe,  we  should  die."  If, 
however,  he  were  asked  the  third  question, 
"  Why  should  we  die  if  we  didn't  breathe  ?  " 
he  would  probably  hesitate  before  answering 
this  question,  if  he  answered  it  at  all,  unless 

305 


TUBERCULOSIS 

he  had  arrived  at  the  grade  where  the  ele- 
ments of  physiology  are  taught  in  the  schools. 

Why  Do  We  Breathe? 

Through  the  medium  of  the  lungs,  as  we 
know,  the  oxygen  is  taken  into  the  body  by 
the  act  of  respiration,  and  carbonic  acid  (car- 
bon dioxid),  a  poisonous  gas,  is  given  off. 
In  other  words,  respiration  does  for  the  body 
what  a  draught  and  a  chimney  do  when  there 
is  a  fire  in  a  room:  it  brings  in  oxygen  to 
unite  with  the  fuel,  the  absorbed  food,  and 
produces  combustion,  and  it  carries  away  car- 
bonic acid,  the  waste  product  of  combustion. 
Through  an  infinite  number  of  minute  blood 
vessels  called  capillaries,  which  cover  the  thin 
walls  of  the  lung  cells,  or  sacs,  called 
"  alveoli,"  all  the  blood  of  the  body  passes 
every  minute  or  two,  and  in  its  passage  the 
oxygen  in  the  air  cells,  which  has  been 
brought  in  by  respiration,  passes  through  the 
thin  cell  walls  and  enters  the  blood,  while  the 
carbonic  acid,  the  waste  product  of  combus- 
tion, passes  out  of  the  blood  into  the  cells  and 
is  carried  away  by  the  act  of  expiration — 
breathed  out. 

After  the  digested  food  is  absorbed — taken 
306 


THE   LUNGS   AND   THEIR   USE 

into  the  blood — it  is  carried  through  the  body 
and  deHvered  to  the  body  cells,  which  con- 
stitute the  body  tissues  and  organs,  according 
to  the  needs  of  each.  Within  these  cells  com- 
bustion takes  place  by  the  union  of  the  elabo- 
rated food  and  the  oxygen,  and,  as  a  result, 
energy  is  generated.  It  is  like  a  fire  in  a 
furnace  under  a  boiler,  which  produces  steam, 
which,  in  turn,  is  transmuted  into  power 
through  the  medium  of  the  steam  engine.  Af- 
ter having  delivered  its  supply  of  fuel  and 
oxygen,  the  blood  takes  up  the  waste  products 
of  combustion,  the  smoke  and  ashes,  so  to 
speak,  and  carries  off  some  through  the  lungs 
in  the  form  of  carbonic  acid,  and  others 
through  the  kidneys  in  other  forms. 

Thus  heat  and  energy  are  constantly  fur- 
nished the  body,  maintaining  a  fixed  tempera- 
ture and  enabling  it  to  carry  on  all  the  vital 
processes  of  life.  We  see,  then,  how  essential 
to  life  and  activity  respiration  is,  and,  like- 
wise, how  important  pure  air  is  to  supply  the 
constant  demand  for  oxygen.  The  lungs  are 
beautifully  adapted  for  the  work  they  have 
to  do.  Let  us  examine  their  mechanism  and 
see  how  they  work. 


3o;r 


TUBERCULOSIS 

The  Cavity  Which  Contains  the  Lungs 

In  the  first  place,  the  lungs  are  safely  en- 
sconced in  the  bony  framework  of  the  chest, 
called  the  thoracic  cavity,  which  is  formed  by 
the  backbone,  or  thoracic  spine,  the  ribs,  which 
are  attached  to  the  spine  by  a  hinged,  or 
movable  joint,  and  in  front  by  the  breast-bone, 
or  sternum,  to  which  the  ribs  are  joined  by  a 
tough,  elastic  substance  called  cartilage.  The 
top  of  this  thoracic  cavity,  or  chest,  is  shut  in 
by  the  muscles  about  the  neck,  and  the  bottom, 
or  base,  is  closed  by  the  diaphragm,  which  is  a 
broad,  thin,  dome-shaped  muscle  attached  all 
around  to  the  bony  framework. 

Besides  the  lungs,  the  chest  cavity  contains 
the  heart,  with  its  great  blood  vessels.  The 
spaces  between  the  ribs  are  closed  by  the  in- 
tercostal or  between-rib  muscles,  and  they, 
with  the  diaphragm,  are  the  principal  muscles 
in  action  in  ordinary  breathing,  though  in 
forced  respiration  other  muscles  about  the 
chest  are  called  into  play.  The  intercostal 
muscles  pull  up  and  out  the  ribs  so  as  to 
enlarge  the  cavity  of  the  chest,  expand  it,  as 
we  say,  and  at  the  same  time  the  diaphragm  is 
drawn  downwards  by  its  own  contraction  so 

308 


THE   LUNGS   AND   THEIR   USE 

as  to  give  the  expanded  lungs  more  room  in 
that  direction. 

The  Mechanism  of  Respiration 

When  the  chest  cavity  is  thus  enlarged,  the 
air  rushes  into  the  lungs  and  expands  them 
so  that  they  fill  up  the  enlarged  space.  This 
is  inspiration.  In  expiration,  the  chest  walls 
recede  and  the  elasticity  of  the  lung  tissue 
contracts  them  and  pushes  out  the  air.  Thus 
inspiration  is  an  active  process,  caused  by 
muscular  contraction,  while  expiration  is  a 
passive  one.  The  act  of  respiration  takes 
place  normally  from  1 6  to  20  times  a  minute. 

In  order  that  the  lungs  may  expand  equally 
in  all  directions,  and  that  their  movement  in 
respiration  may  take  place  smoothly  and  with- 
out friction,  the  inside  of  the  chest  is  lined 
with  a  thin,  delicate  membrane,  called  the 
pleura,  which  has  double  walls,  the  outer  one 
being  attached  to  the  chest  wall  and  diaphragm 
and  the  inner  one  to  the  lungs.  The  surface 
of  the  pleurae  is  kept  moist  with  a  thin,  yel- 
lowish fluid,  which  serves  the  same  purpose 
as  oil  on  the  bearings  of  any  piece  of  ma- 
chinery. Thus,  in  healthy  respiration,  the 
movement  of  the  lungs  is  without  sensation. 

309 


TUBERCULOSIS 

When,  however,  the  pleurae  become  roughened 
by  inflammation,  as  they  not  infrequently  do, 
we  at  once  experience  pain  in  breathing, 
which  we  call  a  "  pleuritic  "  pain,  or  "  pleu- 
risy," and  in  order  to  avoid  the  pain  we  in- 
voluntarily restrict  the  respiratory  movements. 

The  Upper  Respiratory  Tract 

The  lungs  are  connected  with  the  outer  air 
by  means  of,  first,  the  nose,  then  the  pharynx 
behind  the  mouth,  next  the  larynx  lower 
down  which  leads  into  the  trachea  or  wind 
pipe,  which  divides  into  two  great  branches, 
one  going  to  each  lung,  called  the  bronchi. 
These  again  are  divided  into  smaller  and 
smaller  branches  until  finally  they  end  in  the 
tiny  air  cells,  or  "  alveoli." 

The  respiratory  tract  is  lined  with  a  mem- 
brane called  "  mucous  membrane,"  and  is 
moistened  with  a  sticky  substance,  "  mucus." 
There  are  also  on  the  inner  walls  of  the  air 
passages  fine  hairlike  processes,  called 
"  cilia."  The  mucus  catches  the  dust  particles 
in  the  respired  air,  and  the  "  cilia,"  which 
have  a  continuous  movement  upwards,  sweep 
out  the  mucus  and  dust,  thus  irritating  sub- 
stances in  the  dust,  and  whatever  bacteria  or 

310 


THE  LUNGS   AND   THEIR  USE 

germs  it  contains  arc  prevented  from  enter- 
ing the  lungs. 

Size,  Weight  and  Capacity  of  the  Lungs 

The  lungs  fit  snugly  into  the  pleura-lined 
chest,  their  rounded  top  or  apex  projecting 
into  the  neck  about  one  and  one-half  inches 
above  the  collar  bone,  or  "clavicle,"  and 
their  concave  base  fitting  accurately  upon  the 
convex  top  of  the  diaphragm.  The  weight  of 
the  lungs  is  between  5  and  6  pounds  in  men, 
and  4  to  5  pounds  in  women.  They  have  been 
compared  to  a  sponge,  because,  as  we  have 
said,  they  are  composed  of  innumerable  cells 
filled  with  air,  and  when  placed  in  water  they 
will  not  sink. 

Any  impediment  to  the  free  movements  of 
the  chest  walls,  or  action  of  the  muscles  of 
respiration,  interferes  with  the  free  expansion 
of  the  lungs.  Such  impediments  are  some- 
times diseased  conditions,  or  deformities  of 
the  chest,  and  sometimes  mechanical  obstruc- 
tions, such  as  improper  posture, — leaning  over 
a  desk ;  or  tight  clothing,  as  corsets. 

When  one  fills  the  lungs  to  their  fullest 
extent  and  then  forces  out  all  the  air  possible, 
the  amount  thus  exhaled  is  called  the  "  vital 

311 


TUBERCULOSIS 

capacity,"  and  is  measured  by  an  instrument 
called  the  "  spirometer."  This  "  vital  ca- 
pacity "  in  the  average  man  is  about  230  or 
240  cubic  inches,  and  in  the  average  woman 
150  cubic  inches.  The  amount  of  air  one 
generally  uses  in  quiet  breathing,  called  the 
"  tidal  air,"  is  about  30  cubic  inches.  Hence 
it  is  seen  how  much  unused  capacity  the  lungs 
have.  In  order,  then,  to  give  the  unused  por- 
tion of  the  lungs  proper  exercise,  we  should 
practice  deep  breathing  just  as  we  exercise 
other  parts  of  the  body.  Full  and  free  respira- 
tion strengthens  the  lung-tissue  and  nourishes 
it  with  well-oxygenated  blood ;  its  vitality  is 
increased  in  direct  proportion  to  its  work,  and 
its  resisting  force  is  thereby  increased. 

Inadequate  Respiration  a  Danger 

On  the  contrary,  inadequate  and  partial 
respiration,  such  as  many  persons  of  sedent- 
ary habits  and  in-door  occupations  are  accus- 
tomed to,  throws  into  disuse  more  or  less  of 
the  lung-tissue,  and  reduces  its  vitality.  In 
consequence  of  this,  the  nutrition  of  the  lungs 
becomes  defective  as  well  as  that  of  the  entire 
body,  and  the  lung-tissue  becomes  an  inviting 
soil  to  disease  and  the  tubercle  bacillus.    The 

312 


THE   LUNGS   AND   THEIR   USE 

deprivation  of  the  pulmonary  exercise  fur- 
nished by  the  articulation  of  words  is  said  to 
be  the  cause  of  the  frequency  of  consumption 
among-  deaf  mutes. 

"  There  is  no  apparatus,"  says  Lagrange, 
"  where  we  can  verify  in  a  more  striking  man- 
ner the  law  that  *  action  makes  the  organ ' 
than  in  the  respiratory ;  no  organ  is  so  rapidly 
modified  as  the  lung  in  accommodating  itself 
to  the  more  active  working  which  is  de- 
manded of  it.'*  The  most  common  seat  of  at- 
tack from  tuberculosis  is  the  tops  or  apices 
of  the  lungs,  and  it  is  just  this  portion  which 
is  so  inactive  in  the  ordinary  breathing  of 
sedentary  life.  As  in  quiet  respiration  the 
diaphragm  is  the  muscle  principally  in  ac- 
tion, there  is  all  the  more  reason  why  the 
person  of  a  quiet  occupation  should  regularly 
practice  deep  breathing  in  order  to  exercise 
and  maintain  in  good  condition  the  other 
muscles  of  respiration. 

"  The  majority  of  people,"  says  Prof. 
Schrotter,  before  quoted,  "  attach  the  greatest 
importance  to  the  ingestion  of  the  food,  and 
even  spend  a  large  proportion  of  their  mental 
activity  on  the  various  details  in  connection 
with  their  meals,  while,  as  a  rule,  the  process 

313 


TUBERCULOSIS 

of  respiration,  with  all  that  belongs  to  it,  is 
regarded  as  being  less  worthy  of  attention,  as 
being  of  subordinate  importance.  But  if  one 
compares  the  10,000  litres  (610,000  cubic 
inches)  of  air  which  a  person  breathes  daily, 
with  the  small  volume  of  solid  and  liquid  food 
used  up  by  a  moderate  eater ;  if  one  considers 
that  the  quality  of  the  air  is  really  much  more 
important  than  that  of  the  diet,  and,  lastly,  if 
one  considers  that  a  person  can  fast  for  days 
but  dies  in  a  few  minutes  if  the  respiration  is 
stopped,  one  realizes  the  error  of  this  view 
and  the  vital  importance  of  the  respiratory 
process." 

We  Should  Breathe  Through  the  Nose 

In  order  to  maintain  the  lungs  in  healthy 
activity,  we  must  have,  first,  a  free  entrance 
of  air  into  them  through  the  upper  respiratory 
passages ;  second,  pure  air ;  third,  an  adequate 
and  unimpaired  breathing  mechanism, — the 
respiration  should  be  full  and  free.  In  the 
first  place,  we  must  breathe  through  the  nose, 
which  was  intended  for  that  purpose.  Mouth- 
breathing  is  pernicious,  for  it  allows  the  dust 
and  whatever  uncleanliness  is  in  the  air  to 
pass  directly  into  the  lungs  without  the  prepa- 
ration and  sifting  which  it  is  subjected  to  in 

314 


THE  LUNGS   AND  THEIR  USE 

the  nose.  A  simple  and  yet  efficacious  method 
of  curing  mouth-breathing  is  to  paste  a  piece 
of  strongly  adhesive  plaster  over  the  mouth 
on  going  to  bed.  The  nasal  passages  should 
be  free,  and  if  narrowing  or  obstructions 
exist,  either  in  front  or  behind,  such  as  devia- 
tions of  the  nasal  septum  (the  dividing  parti- 
tion) in  front,  or  adenoid  growths  behind, 
they  should  be  removed. 

The  peculiar  structure  of  the  nasal  passage, 
which  forms  a  sort  of  winding  route  for  the 
air  in  its  course  through  it,  "  over  hill  and 
dale,"  enables  it  thus  to  sift  the  air,  and  free 
it  to  a  great  extent  from  dust  and  germs; 
warm  and  moisten  it,  so  that  it  finally  enters 
the  lungs  clean  and  of  the  proper  temperature 
and  moisture.  Even  very  cold  air  is,  to  a 
certain  extent,  warmed  in  the  nose,  so  that 
one  can  breathe  the  air  of  the  Arctic  regions 
with  impunity.  Warm  air  likewise  does  not 
injure  the  lungs.  It  is  a  marvelous  provision 
of  Nature  which  enables  one  to  breathe  air 
fifty  degrees  below  zero  and  one  hundred  and 
fifty  degrees  above,  without  harm. 

Importance  of  Pure,  Fresh  Air 

Very  dry  and  hot  air,  such  as  that  so  often 
found  in  a  furnace-heated  room  in  winter, 

315 


TUBERCULOSIS 

dries  up  the  nose  and  throat,  and  interferes 
with  the  action  of  the  "cilia,"  those  con- 
stantly moving  sweepers.  It  is,  therefore,  im- 
portant that  there  should  be  some  means  in 
living  rooms  for  maintaining  a  sufficient 
amount  of  moisture  in  the  air;  an  average 
relative  humidity  of  about  70  per  cent,  is  most 
wholesome  and  comfortable. 

The  air  which  we  breathe  should  be  pure 
and  fresh,  as  we  have  learned  many  times  in 
the  course  of  this  narrative.  It  should  be 
free  from  dust,  smoke  and  carbonic  acid,  as 
in  air  breathed  and  rebreathed  in  a  crowded 
room  with  insufficient  ventilation.  Absolutely 
pure  air  can  nowhere  be  obtained  in  civilized 
communities, — there  are  always  more  or  less 
impurities  in  it ;  but  we  can  breathe  the  purest 
air  there  is  about  us.  Night  air,  as  has  been 
before  mentioned,  is  as  good  as,  and  some- 
times purer  than,  day  air.  The  inhalation  of 
smoke,  a  common  habit  with  cigarette  smok- 
ers, irritates  the  delicate  lung-tissue,  and 
renders  it  more  susceptible  to  infectious 
germs. 

Respiratory  Exercises 
With  a  free  passage  through  the  nose,  and 
316 


THE  LUNGS   AND   THEIR  USE 

the  purest  air  we  can  obtain,  the  next  thing 
is  to  ensure  full  and  free  respiration,  and  this 
we  must  do  by  general  and  respiratory  exer- 
cises. 

(a)  General  Exercises:  Many  general  ex- 
ercises are  good  for  respiration,  such  as  swim- 
ming, running,  tennis,  skating,  rowing,  moun- 
tain climbing,  free  hand  class  work  in  a  gym- 
nasium, dancing,  singing,  rope  jumping,  etc. 
It  is  said  that  rope  jumping  is  a  common  form 
of  exercise  with  boxers  for  increasing  the 
'*  wind."  All  exercises  which  bring  the  legs 
into  violent  action  are  especially  good  for 
respiration  on  account  of  the  number  and  size 
of  the  muscles  employed. 

(b)  Special  Exercises:  Besides  these  gen- 
eral exercises,  there  are  other  direct,  or  local, 
respiratory  ones,  especially  directed  to  the  de- 
velopment of  the  respiratory  muscles  and 
lungs.  These  especial  respiratory  exercises 
are  simple  and  yet  efficacious,  such  as,  stand- 
ing erect  in  a  well-ventilated  room,  or,  better, 
out-doors,  with  the  hands  on  the  hips  and  tak- 
ing long,  deep  inspirations  and  slow  expira- 
tions, beginning  at  the  bottom  of  the  chest  and 
filling  up,  so  to  speak.  This  alone,  done  sev- 
eral times   a  day,   will   often  materially   in- 


TUBERCULOSIS 

crease  the  lung  capacity.  "  Numerous  obser- 
vations," says  Lagrange,  "  prove  that  it  is 
enough  voluntarily  to  take  a  certain  number 
of  deep  breaths  every  day  to  produce  in  a 
short  time  an  increase  in  the  circumference  of 
the  chest  which  may  amount  to  two  or  three 
centimetres."  Then  there  are  the  various  arm 
movements  in  connection  with  deep  breathing, 
such  as  slowly  raising  the  outstretched  arms 
to  a  horizontal  position  and  then  overhead 
until  the  hands  meet,  slowly  and  deeply  in- 
spiring while  raising  the  arms,  then  holding 
the  breath  a  moment,  and,  finally,  lowering 
the  arms  and  exhaling.  Thus  the  supplement- 
ary respiratory  muscles  of  the  chest  are 
brought  into  action.  Again,  raising  the  arms 
to  a  horizontal  position  and  carrying  them 
back  and  down,  describing  a  movement  of 
circumduction ;  standing  erect  and  straighten- 
ing up,  and,  finally,  rising  upon  one's  toes, 
deeply  inspiring  during  this  movement;  lying 
on  the  back  horizontally  upon  the  floor,  or  a 
table,  and  raising  the  arms  backward  and  over 
the  head  while  inspiring.  If  the  table  is  nar- 
row, the  arms  can  describe  a  circle  about  the 
head. 

Still  another  simple  breathing  exercise  men- 
tioned by  Schrotter  is  the  following:     The 

318 


THE   LUNGS   AND   THEIR   USE 

chest  being  well  thrown  forward  and  the  arms 
placed  akimbo,  the  shoulders  are  moved  back- 
wards in  jerks  as  far  as  possible,  and  then  a 
deep  inspiration  is  taken.  This  can  be  taken 
while  walking  out-of-doors.  In  the  Swedish 
system  of  gymnastics,  there  are  almost  an  in- 
numerable variety  of  respiratory  exercises, 
most  of  which,  however,  are  but  modifications 
and  combinations  of  a  few  simple  movements, 
and  many  can  be  performed  without  appa- 
ratus. Again,  there  are  the  common  gym- 
nastic apparatus  for  increasing  the  lung 
capacity  and  developing  the  respiratory  mus- 
cles, such  as  the  so-called  "  chest  developers  " 
and  "  lung  expanders."  The  Zander  appara- 
tus can  also  be  the  ones  for  the  same  purpose. 
After  all,  the  simple  deep-breathing  exer- 
cises will  be  the  ones  most  generally  applica- 
ble, for  anyone  can  do  them  anywhere.  After 
sitting  at  the  desk  for  a  long  time,  particularly 
if  bent  over,  it  is  a  good  plan  to  stand  up  and 
spend  a  few  minutes  in  practicing  some  of  the 
simple  breathing  exercises.  "What  is  gen- 
erally described  as  overwork,"  to  quote  Prof. 
Schrotter  again,  "  is  really  the  effect  of  stay- 
ing too  long  in  a  close  atmosphere  and  of  an 
insufficient  activity  of  the  respiratory  organs." 


319 


TUBERCULOSIS 

The  Corset 

It  is  hardly  necessary  to  say  that  in  taking 
breathing  exercises  one  should  be  so  dressed 
as  not  to  impede  the  free  movement  of  the 
chest.  The  corset  has  already  been  referred 
to.  From  time  immemorial  physicians  have 
decried  them  as  interfering  with  the  free 
movement  of  the  chest  in  respiration,  and  im- 
pairing the  integrity  of  the  respiratory  mus- 
cles. From  time  immemorial  women  have 
worn  them,  and  will  probably  always  continue 
to  do  so,  in  spite  of  the  evils  from  them  which 
they  too  well  know.  It  is  fortunate  that  they 
are  removed  at  night,  and  thus  for  a  portion 
of  the  twenty- four  hours  the  lungs  are  al- 
lowed free  play. 

The  Habit  of  Full,  Free  Respiration 

Once  having  established  a  proper  respira- 
tion by  the  use  of  some  of  the  simple  respira- 
tory exercises,  and  devoting  a  few  minutes  to 
them  every  day,  the  habit  of  full,  deep  breath- 
ing is  formed,  and  one  continues  it  to  a 
greater  or  less  degree  even  when  in  repose. 
And,  further,  one  is  thus  fortifying  himself 
against  the  possibility  of  disease  of  the  lungs 
by  thus  maintaining  the  pulmonary  tissue  in 

320 


THE  LUNGS  AND  THEIR  USE 

an  active,  healthy  and  well-nourished  condi- 
tion, and  it  is  less  likely  to  become  a  favora- 
ble soil  for  the  tubercle  bacillus. 

Let  me  repeat  and  emphasize  in  closing, 
that  this  matter  of  chest  expansion  and  proper 
respiration  is  of  vital  importance  to  every  one, 
particularly  to  those  of  sedentary  habits.  By 
employing  this  simple  precaution,  we  not  only 
put  ourselves  in  the  most  favorable  condition 
to  avoid  pulmonary  weakness  and  disease,  but 
maintain  the  whole  circulation  in  a  healthy 
condition,  which  means  vigor  and  well-being 
to  the  entire  system.  A  nation  of  deep 
breathers  can  do  much  toward  stamping  out 
and  banishing  forever  the  "  Great  White 
Plague." 


321 


FRESH   AIR^ 

The  more  fresh  air  we  give  to  our  school- 
children the  healthier  and  brighter  will  they  be, 
and  the  faster  will  they  get  ahead.  This  has 
been  proved. 

The  same  is  true  of  workers  in  shops,  offices, 
and  factories.  Shall  they  not  be  helped  to  do 
their  best  work? 

Get  more  fresh  air  into  your  workshops  and 
places  of  business. 

Remember,  fresh  air  is  needed  in  our  homes. 
Night  air  is  just  as  good  as  day  air. 

The  air  in  theaters  and  restaurants  and  pub- 
lic halls,  crowded  as  such  places  are  every 
night,  ought  also  to  be  kept  fresh.  Patronize 
only  those  that  are  well  ventilated. 

Fresh  air  is  entirely  free.  It  is  always  wait- 
ing just  outside  the  window-pane.  Don't  be 
stingy  with  it!     Let  it  in! 

Always  work,  sleep,  and  play  where  fresh 
air  is  plenty,  and  keep  out-of-doors  whenever 
possible. 

When  in  doubt — open  a  window. 

1  Prepared  by  the  Boston  Association  for  the 
Relief  and  Control  of  Tuberculosis. 

322 


HEALTH   RULES  ^ 

Good  Air 

Keep  away  from  badly  ventilated,  badly 
lighted,  dusty,  dirty,  over-heated,  crowded  or 
damp  rooms.     Keep  a  window  open. 

Avoid  House  Dust 

Breathing  house  dust  often  causes  disease. 

Have  no  tacked-down  carpets  and  mattings. 

For  floor  coverings  use  rugs  or  strips  of  car- 
pets, and  clean  them  frequently  outdoors. 

Use  a  broom  or  mop  for  floors  and  keep 
lower  half  of  window  closed  while  sweeping  or 
dusting. 

Open  upper  half  of  window  if  possible. 
When  sweeping  rugs  or  carpets  dampen  the 
broom  or  use  wet  sawdust  or  wet  pieces  of 
paper,  and  in  winter  use  dry  snow.  This  will 
keep  the  dust  from  flying  about. 

Pure  Water 

Drink  pure  water  from  the  tap. 
Boston  water  is  safe  to  drink. 

1  Prepared  by  the  Boston  Association  for  the 
Relief  and  Control  of  Tuberculosis. 


TUBERCULOSIS 

Water  standing  in  ice-water  tanks  may  be- 
come contaminated. 

Avoid  public  drinking  cups. 

Keep  Clean 

Take  a  bath  or  wash  the  body  with  a  wet 
sponge  or  cloth  every  day.  If  you  have  no 
bath  tub  use  the  public  bath. 

Do  not  use  towels  hung  up  for  common  use. 

Use  pure  soap  freely. 

Wash  your  hands  thoroughly,  and  clean  your 
finger  nails  before  handling  food. 

Do  not  put  fingers,  money,  paper,  or  pencils 
in  your  mouth. 

Do  not  put  in  your  mouth  fruit,  candy,  or 
chewing  gum  used  by  another. 

Do  not  bite  your  finger-nails. 

Clean  your  teeth  every  day,  using  your  own 
tooth  brush. 

Food 

Do  not  eat  food  that  has  been  exposed  to 
flies  or  dust,  or  touched  by  unclean  hands. 

Fruit  and  vegetables  should  be  rinsed  or 
washed  thoroughly  before  using. 

Chew  your  food  well. 

Good  teeth  promote  good  health. 

324 


HEALTH    RULES 

Sleep 

Get  enough  sleep.  Most  people  need  8 
hours  a  day. 

Growing  children  need  lo  hours. 

Sleep  with  windows  open  and  when  possible 
outdoors. 

Head  Erect 

Sit  and  stand  erect. 

Practise  deep  breathing.     Breathe  through 
the  nose,  keeping  the  mouth  closed. 
Avoid  tight  clothing. 
Stand  on  both  feet. 

Exercise 

Take  plenty  o£  out-door  exercise. 

Avoid  excess  in  athletics.  Too  much  exer- 
cise may  cause  heart  trouble. 

Do  not  eat  or  drink  when  overheated. 

Do  not  exercise  soon  after  eating. 

Tobacco  and  Liquor 

Do  not  use  tobacco,  liquor  or  beer.  Drink- 
ing or  smoking  is  especially  injurious  to  the 
young. 

No  athlete  in  training  is  allowed  to  drink  or 
smoke. 

Tea  drinking  is  bad  for  growing  children. 

325 


TUBERCULOSIS 

Do  Not  Neglect  Colds 

Do  not  neglect  coughs  or  colds.  If  you  do 
not  get  well  soon,  go  to  a  doctor  or  dispensary 
for  treatment. 

Never  cough  or  sneeze  into  another  person's 
face. 

Use  a  handkerchief  or  turn  your  head  away. 

Do  not  spit  on  floors  or  sidewalks. 

Sunshine 

Let  plenty  of  sunshine  into  your  rooms. 

Joy  is  a  great  tonic. 

Happiness  in  work  brings  success. 


326 


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